UNIVERSITY  OF  CALIFORNIA 
AT   LOS  ANGELES 


GIFT  OF 

David  D.   Thornton 


TEXT-BOOK 


OF 


PEDIATRICS 

EDITED  BY 

PROFESSOR  E.  FEER 

DIRECTOR   OF   THE    UNIVERSITY   CHILDREN'S   CLINIC,    ZURICH 


TRANSLATED  AND  EDITED  BY 

JULIUS  PARKER  SEDGWICK,  B.  S.,  M.  D. 

PROFESSOR   OF   PEDIATRICS,    UNIVERSITY   OF   MINNESOTA,    MEDICAL   SCHOOL 

AND 

CARL  AHRENDT  SCHERER,  M.D.,  F.A.C.P. 

DULUTH,    MINNESOTA 


262  ILLUSTRATIONS 


FIRST  EDITION   IN  ENGLISH 


PHILADELPHIA  AND  LONDON 
J.  B.   LIPPINCOTT   COMPANY 


COPYRIGHT,  1922,  BY  J.  B.  LIPPINCOTT  COMPANY 


PRINTED  BY  J.  B.  LJPPINCOTT  COMPANY 

AT  THE  WASHINGTON  SQUARE  PRliSS 

PHILADELPHIA,  TJ.  S.  A. 


PREFACE 

THE  introduction  of  this  work  to  the  physician  and  student  is  made  easy 
by  the  widespread  and  favorable  acquaintance  it  has  achieved  among  those 
who  have  studied  on  the  Continent  or  have  read  it  in  the  original.  The 
preface  to  the  first  edition  sets  forth  the  value  of  a  text  produced  by  the 
collaboration  of  a  number  of  authors,  each  a  master  of  his  branch  of  the 
specialty.  The  plan  of  collaboration  has  been  carried  on  in  the  translation. 
Up  to  the  present  no  similar  one  volume  work  has  appeared  upon 
the  market. 

A  further  distinct  advantage  is  the  concise  treatment  of  the  subject 
matter.  The  arrangement  is  such  that  no  time  is  lost  in  referring  to  any  one 
descriptive  passage.  The  etiology,  pathology,  symptomatology  and  treat- 
ment are  all  complete,  but  as  short  as  compatible  with  their  purpose.  The 
book  covers  the  entire  field  of  pediatrics  as  completely  as  more  bulky  vol- 
umes. The  discussions  of  the  individual  disease  conditions  are  absolutely 
dependable  and  the  therapeutic  measures  advised  are  in  line  with  the  most 
recent  accepted  usage. 

Due  to  the  interest  of  the  American  collaborators  much  has  been  added 
to  the  original  subject  matter  and,  through  the  kindness  of  numerous  friends, 
who  know  the  book  in  the  original,  a  large  number  of  illustrations  have  also 
been  added.  The  editors  take  this  opportunity  to  thank  their  associates, 
by  whose  help  we  were  enabled  to  bring  this  work  to  completion,  for  their 
keen  interest  and  their  painstaking  study  of  the  sections  revised  by  them. 
We  also  wish  to  thank  Dr.  R.  O.  Beard,  Secretary  of  the  Medical  School 
of  the  University  of  Minnesota,  for  his  careful  revision  of  the  English. 
To  J.  B.  Lippincott  Company  we  feel  especially  indebted  for  their  patience 
and  their  appreciation  of  the  problems  of  the  translation. 

May  the  volume  find  as  great  a  sphere  of  usefulness  in  this  translation 
as  it  has  had  in  the  original. 

J.  P.  S. 
C.  A.  S. 
November  1st,   1922. 


PREFACE  TO  FIRST  GERMAN  EDITION 

A  LARGE  number  of  medicaltext-books,the  products  of  the  collaboration  of 
a  number  of  authors,  have  recently  appeared.  The  great  favor  with  which 
these  works  are  received  is  the  best  indication  of  their  value.  When,  there- 
fore, I  was  approached  in  1909  by  Mr.  Gustaf  Fisher  with  the  suggestion 
that  I  edit  a  work  of  this  nature,  as  a  companion  piece  to  the  text  on 
Internal  Medicine  by  Krehl-Mering,  I  had  no  hesitancy  especially  since 
pediatrics  is  no  longer  a  subject  in  which  one  author  can  have  complete 
knowledge  of  all  branches.  I  was  able  to  interest  a  number  of  the  most 
prominent  pediatrists  who  were  competent  to  write  on  the  special  subjects 
assigned  to  them.  I  believe  that  the  work  of  these  associates  and  the  new 
method  of  presenting  the  subject  in  this  volume  with  its  numerous  apt 
illustrations  justify  its  production  in  spite  of  the  great  number  of  text-books 
on  pediatrics  already  on  the  market. 

In  order  to  give  the  student  and  general  practitioner  an  introduction 
into  the  subject  and  an  understanding  of  the  child  itself,  it  has  been  thought 
fit  to  make  the  general  part  very  extensive.  In  the  special  part,  those 
diseases  not  peculiar  to  childhood  and  fully  described  in  text-books  of  gen- 
eral medicine  were  merely  touched  upon,  in  order  to  give  space  to  the 
diseases  that  present  definite  peculiarities  in  childhood  or  occur  only  in 
children.  A  certain  amount  of  duplication  must  of  course  occur,  as  for 
instance  in  those  diseases  classed  as  acute  infections  or  "  children's  diseases." 
These  are  all  considered  in  texts  on  general  medicine,  but  belong  specifically 
to  this  work.  Special  pains  were  taken  to  give  full  space  to  those  diseases 
of  childhood  that  are  barely  touched  upon  in  general  texts,  but  are  of  great 
importance  to  the  podiatrist.  Thus  the  subjects  of  varicella,  pertussis  and 
measles,  given  only  one,  two  and  one  pages  respectively  in  the  Krehl-Mering 
text,  have  been  accorded  seven,  ten  and  two  and  a  half  pages  in  this  book. 

More  space  than  is  customary  is  devoted  to  early  infancy.  The  disturb- 
ances of  nutrition  are  discussed  by  the  most  able  authors  in  accordance 
with  most  recent  research.  Those  physicians  who  are  accustomed  to  the  old 
classification  of  dyspepsia,  catarrh  and  enteritis,  may  be  somewhat  confused 
at  first.  The  discussion  of  the  disturbance  of  nutrition  is  based  upon  the 
study  of  the  nutritional  processes  in  the  light  of  functional  tests.  These 
have  led  to  a  new  classification  and  a  more  rational  treatment.  The  older 
classification,  though  simple,  is  actually  of  little  value  as  far  as  treatment  is 
concerned.  Those,  however,  who  have  already  acquired  this  more  recent 
view  as,  no  doubt,  all  undergraduates  have,  will  gladly  recognize  its  great 
advances  and  will  take  advantage,  clinically,  of  the  benefits  afforded  by  it 
in  the  treatment  of  the  disturbances  of  nutrition,  a  most  difficult  phase  of 
the  practice  of  pediatrics. 

As  far  as  the  use  of  varied  sizes  of  print  is  concerned,  the  small  print 
is  used  for  introductions  and  notes  of  a  more  or  less  general  nature,  not 


vi  PREFACE  TO  SEVENTH  GERMAN  EDITION 

having  direct  bearing  upon  the  subject  under  discussion,  but  essential  for  its 
understanding  and  to  be  especially  brought  to  the  reader's  notice. 

The  excellent  ensemble  of  the  work  is  due  to  the  interest  and  painstaking 
care  of  the  publisher  who  has  spared  no  means  to  produce  the  best  at  a 
reasonable  price.  His  efforts  have  further  made  it  possible  to  obtain  new 
illustrations  that  are  most  applicable  to  the  text. 

May  this  new  text-book  be  a  reliable  guide  and  advisor  to  both  the 
undergraduate  and  practicing  physician. 

E.  FEER. 


PREFACE  TO  SEVENTH  GERMAN  EDITION 

THE  demand  for  a  new  edition,  so  soon  after  the  appearance  of  the  last, 
has  necessitated  but  few  changes.  Nevertheless,  all  the  authors  have 
revised  their  sections  and  made  additions  and  improvements.  Special  pains 
have  been  taken  to  enlarge  upon  the  therapy.  By  more  concise  handling 
of  several  sections,  it  has  been  possible  to  reduce  the  size  of  the  volume 
by  twenty-four  pages. 

In  place  of  our  late  colleague,  Professor  Tobler,  Professor  Noeggerath 
consented  to  take  on  a  portion  of  the  work  and  has  completely  revised  the 
section  on  genito-urinary  diseases,  bringing  out  the  advances  made  during 
the  last  few  years  in  the  study  of  the  nephropathies. 

Furthermore,  we  must  again  report  the  loss  of  a  colleague,  Professor 
Martin  Thiemich,  who  died  February  16,  1921,  following  a  long  illness,  at 
the  age  of  fifty-one.  This  was  a  great  loss  not  only  to  our  text-book  but  also 
to  the  science  of  pediatrics  and  the  University  of  Leipzig.  His  last  work 
was  the  correction  and  revision  of  his  section  of  this  text. 

E.  FEER. 


TEXT-BOOK  OF  PEDIATRICS 

EUROPEAN  CONTRIBUTORS 

PEER,  E.,  PROFESSOR  DR.,  Zurich. 
FINKELSTEIN,  H.f  PROFESSOR  DR.,  Berlin. 
IBRAHIM,  J.,  PROFESSOR  DR.,  Jena. 
MEYER,  L.  P.,  PRiv.-Doz.  DR.,  Berlin. 
MORO,  E.,  PROFESSOR  DR.,  Heidelberg. 
NOEGGERATH,  C.,  PROFESSOR  DR.,  Freiburg  i  Br. 
THIEMICH,  M.;  PROFESSOR  DR.,  Leipzig. 
v.  PFAUNDLER,  M.,  PROFESSOR  DR.,  Munich. 
v.  PIRQUET,  CL.  FRH.,  PROFESSOR  DR.,  Vienna. 

AMERICAN  COLLABORATORS 

BRENNEMANN,  JOSEPH,  M.D.,  Chicago,  111. 

Attending  Pediatrist,  Children's  Hospital,  Chicago. 
BYFIELD,  ALBERT  H.,  M.D.,  Iowa  City,  la. 

Professor  of  Pediatrics,  College  of  Medicine,  State  University  of  Iowa. 
CALHOUN,  HENRIETTA  M.A.,  M.D.,  Iowa  City,  la. 

Assistant  professor  of  Pathology,  College  of  Medicine,  State  University  of  Iowa. 
DE  BUYS,  L.  R.,  M.D.,  F.A.P.C.,  New  Orleans,  La. 

Professor   of  Diseases  of  Children,  School  of  Medicine,  Tulane  University   of 

Louisiana;  Chief  of  Pediatrics,  Turo  Infirmary. 
DIETRICH,  HENRY,  M.D.,  Los  Angeles,  California. 

'  Attending  Pediatrist,  Children's  Hospital,  Los  Angeles. 
FLEISCHNER,  E.  C.,  M.D.,  San  Francisco,  Calif. 

Clinical  Professor  of  Pediatrics,  University  of  California. 
HESS,  JULIUS  H.,  M.D.,  Chicago,  111. 

Professor  and   Head  of  the  Department  of  Pediatrics,  University  of  Illinois, 

College  of  Medicine;  Chief  of  Pediatric  Staff,  Cook  County  Hospital. 
HOFFMANN,  WALTER  H.  O.f  M.D.,  Chicago,  111. 

Associate  Attending  Pediatrist,  Children's  Memorial  Hospital,  Chicago. 
HOOBLER,  B.  RAYMOND,  M.D.,  Detroit,  Mich. 

Professor  of  Pediatrics,  Detroit  College  of  Medicine  and  Surgery. 
IRVINE,  HARRY  GARFIELD,  M.D.,  Minneapolis,  Minn. 

Associate  Professor  of  Dermatology  and  Syphilis,  Medical  School,  University  of 

Minnesota;  Director  of  the   Division   of  Venereal  Diseases,    Minnesota  State 

Board  of  Health. 
JEANS,  PHILIP  C.,  St.  Louis,  Mo. 

Associate  Professor  of  Pediatrics,  Washington  University  School  of  Medicine* 
MEYER,  K.  F.,  M.D.,  San  Francisco,  Calif. 

Professor  of  Research  Medicine,  University  of  California. 
OTT,  M.  D.,  M.D.,  Minneapolis,  Minn. 

Associate  in  Pediatrics,  University  of  Minnesota,  Medical  School. 
PIERCE,  NABOTH  OSBORNE,  M.D.,  Minneapolis,  Minn. 

Assistant  Professor  of  Pediatrics,  University  of  Minnesota,  Medical  School, 
SCAMMON,  RICHARD  EVERINGHAM,  M.D.,  Minneapolis,  Minn. 

Professor  of  Anatomy,  University  of  Minnesota,  Medical  School. 


CONTENTS 


GENERAL  CONSIDERATIONS 

by 
PROFESSOR  DR.'  MARTIN  THEIMICH, 

Director  of  the  University  Children's  Clinic,  Leipzig. 

PAGE 

I.  ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES 1 

Revised  and  Edited  by 
DR.  RICHARD  EVERINGHAM  SCAMMON,  Minneapolis,  Minn., 

Professor  of  Anatomy,  University  of  Minnesota  Medical  School. 

II.  CARE  AND  FEEDING  OF  THE  NORMAL  INFANT 36 

Revised  and  Edited  by 
JULIUS  H.  HESS,  M.  D.,  Chicago,  111., 

Professor  and  Head  of  the  Department  of  Pediatrics,  University  of  Illinois,  College  of 
Medicine,  Chief  of  Pediatrie  Staff,  Cook  County  Hospital. 

III.  GENERAL  SYMPTOMATOLOGY  AND  TECHNIC  OF  EXAMINATION 70 

Revised  and  Edited  by 
L.  R.  DEBUYS,  M.  D.,  F.  A.  C.  P.,  New  Orleans,  La., 

Professor   of   Diseases   of   Children,   S?hool  of  Medicine,   Tulane   University  of 
Louisiana;  Chief  of  Pediatrics,  Turo  Infirmary. 


IV.  GENERAL  PATHOGENESIS,  MORTALITY  AND  MORBIDITY 

Revised  and  Edited  by 
B.  RAYMOND  HOOBLER  M.  D.,  Detroit,  Mich., 

Professor  of  Pediatrics,  Detroit  College  of  Medicine  and  Surgery. 


V.  GENERAL  PROPHYLAXIS  AND  THERAPY 98 

Revised  and  Edited  by 
ALBERT  H.  BYFIELD,  M.  D.,  IOWA  CITY,  IOWA., 

Professor  of  Pediatrics,  College  of  Medicine,  State  University  of  Iowa. 

SPECIAL  PART 

SECTION  I.  DISEASES  OF  THE  NEW-BORN 

by 
PROFESSOR  DR.  MED.  AND  PHIL.  HEINRICH  FINKELSTEIN, 

Director  of  the  Kinderkrankenhaus,  Berlin, 
and 

PRIVATDOZENT  DR.  LUDWIG  MEYER, 

Chief  Pediatrist  to  the  Orphanage  and  Children's  Asylum  of  the  City  of  Berlin. 

Revised  and  edited  by 
NABOTH  OSBORNE  PIERCE,  M.  D.,  Minneapolis,  Minn., 

Assistant  Professor  of  Pediatrics,  University  of  Minnesota,  Medical  School. 

DISEASES  OF  THE  NEW-BORN 121 

ASPHYXIA 125 

BIRTH  TRAUMATA 127 

EXTERNAL  CEPHALHEMATOMA : 127 

INTERNAL  CEPHALHEMATOMA 129 

CEREBRAL  HEMORRHAGE  ...  .   129 


CONTENTS 

PAGE 

HEMATOMA  OF  THE  STERNOCLEIDOMASTOID 130 

PARALYSES ,00 

DISEASES  OF  THE  UMBILICUS 

CONGENITAL  ANOMALIES 

INFECTIONS  OF  THE  UMBILICUS 

GANGRENE  OF  THE  STUMP ..  „„ 

BLENNORRHEA ^ - 

UMBILICAL  ULCER • • ,  oQ 

UMBILICAL  FUNGUS   (GRANULOMA  OF  THE  UMBILICUS)  •••••• "» 

OMPHALITIS  (ACUTE  INFLAMMATION  OF  THE  UMBILICAL  KING) i^y 

GANGRENE  OF  THE  UMBILICUS j^l 

MIGRATORY  INFECTION „ 

TETANUS  NEONATORUM ™ 

UMBILICAL  HEMORRHAGE JT: 

SEPSIS 1 4£ 

MELENA  NEONATORUM j|* 

ERYSIPELAS |CQ 

OPHTHALMIA  NEONATORUM • ***? 

SWELLING  OF  THE  MAMMARY  GLAND  AND  MASTITIS 101 

ICTERUS  NEONATORUM J^ 

EDEMA  AND  SCLEREDEMA  OF  THE  NEW-BORN 


ALBUMINURIA 

URIC  ACID  INFARCTS  . .  . 
VAGINAL  HEMORRHAGE. 


154 


SECTION  II.  PATHOLOGICAL  CHANGES  OF  THE  BLOOD  AND 
BLOOD-FORMING  ORGANS 

CONSTITUTIONAL  ANOMALIES  AND  DISEASES  OF  METABOLISM 

by 
PROFESSOR  DR.  MEINHARD  VON  PFAUNDLER, 

Director  of  the  University  Children's  Clinic,  Munich. 

Revised  and  Edited  by 

M.  D.  OTT  M.  D.,  Minneapolis,  Minn., 

Associate  in  Pediatrics,  University  of  Minnesota,  Medical  School. 

INTRODUCTION 156 

PHYSIOLOGY  AND  PATHOLOGY  OF  THE  BLOOD 156 

A.  GROUP  OF  ANEMIAS  (GENERAL  SYMPTOMATOLOGY) 159 

ANEMIA  DUE  TO  PRIMARY  INTERFERENCE  WITH  ERYTHROPOIESIS 161 

ANEMIAS  DUE  TO  Loss  OF  BLOOD .' 164 

HEMOCYTOLYTIC  AND  MYELOPATHIC  ANEMIAS 165 

THE  TREATMENT  OF  ANEMIA 172 

APPENDIX:  PSEUDO-ANEMIAS 174 

B.  GROUP  OF  LEUCEMIAS  AND  PSEUDOLEUCEMLAS 175 

LYMPHOCYTOMATOSES 176 

LEUCEMIC  LYMPHADENOSIS  OR  LYMPHATIC  LEUCEMIA 176 

LYMPHOSARCOMATOSES 178 

THE  MYELO-CYTOMATOSES 179 

MYELOSARCOMATOSES 181 

CHOROMATA 181 

GRANULOMATOSES 182 

PATHOGENESIS  OF  LEUCEMIA  AND  PSEUDOLEUCEMIA 183 

THERAPY 183 

HEMORRHAGIC  DIATHESIS  OR  TENDENCY  TO  HEMORRHAGE 184 

INFANTILE  SCURVY   (BARLOW'S  DISEASE) 186 

RICKETS 190 

CLINICAL  SYMPTOMS  AND  THEIR  ORIGIN 196 

SKELETAL  MANIFESTATIONS 196 

COURSE,  COMPLICATIONS:  TERMINATION 203 

DIFFERENTIAL  DIAGNOSIS 203 

DIABETES  MELLITUS 208 

OBESITY 210 

UNDER-NOURISHED  OR  FRAIL  CHILDREN  . .  .211 


CONTENTS  xi 

PAGE 

TREATMENT 213 

PECULIAR  PREDISPOSITIONS  TO  DISEASE  (DIATHESES)  AND  CONSTITU- 
TIONAL ANOMALIES 213 

THE  INFLAMMATORY  OR  EXUDATIVE  DIATHESIS 214 

ARTHRITISM  IN  CHILDHOOD 221 

APPENDIX:  PATHOLOGY  OP  THE  GLANDS  OF  INTERNAL  SECRETION 226 

A.  PATHOLOGY  OF  THE  THYROID 226 

HYPOTHYREOSIS;  ATHYREOSIS 226 

GENERAL  SYMPTOMS  AND  THEIR  CAUSES 227 

SPECIAL  CLINICAL  CONSIDERATIONS  OF  HYPOTHYREOSES 231 

INFANTILISM 233 

TREATMENT 233 

GOITRE 234 

BASEDOW'S  DISEASE ; 235 

INFANTILE  BASEDOWOID  DISEASE 235 

B.  PATHOLOGY  OF  THE  GERMINAL  ORGANS 235 

C.  PATHOLOGY  OF  THE  HYPOPHYSIS 236 

D.  DISTURBANCES  OF  GROWTH 236 

GENERAL  PHYSICAL  ANOMALIES  OCCURRING  WITHOUT  RECOGNIZED  RE- 
LATION TO  THE  HEMIC  GLANDS 236 

OSTEOGENESIS  IMPERFECTA  (VROLIK) 237 

OSTEOPSATHYROSIS 237 

SECTION  III.  DISEASES  OF  THE  DIGESTIVE  SYSTEM 

by 
PROFESSOR  DR.  MED.  AND  PHIL.  HEINRICH  FINKELSTEIN, 

Director  of  the  Kinderkrankenhaus,  Berlin, 
and 

PRIVATDOZENT  DR.  LUDWIG  MEYER, 

Chief  Podiatrist  to  the  Orphanage  and  Children's  Asylum  of  the  City  of  Berlin. 

Revised  and  Edited  by 
JOSEPH  BRENNEMANN,  M.  D.,  Chicago,  111., 

Attending  Podiatrist,  Children's  Memorial  Hospital,  Chicago. 

DISEASES  OF  THE  MOUTH 242 

STOMATITIS 242 

ANOMALIES  OF  THE  TEETH  AND  TEETHING 247 

DISEASES  OF  THE  SALIVARY  GLANDS 248 

DISEASES  OF  THE  TONSILS,  THE  PHARYNX  AND  THE  ESOPHAGUS 248 

ANGINA 248 

CATARRHAL  ANGINA  AND  EXUDATIVE  ANGINA 249 

HYPERPLASIA  OF  THE  TONSIL 252 

RETROPHARYNGEAL  LYMPHADENITIS  AND  RETROPHARYNGEAL  ABSCESS.  .  252 

CONGENITAL  ANOMALIES  OF  THE  ESOPHAGUS 254 

ACQUIRED  DISEASES  OF  THE  ESOPHAGUS 254 

NUTRITIONAL  DISTURBANCES  OF  INFANTS 255 

DISTURBANCES  OF  NUTRITION  OF  THE  ARTIFICIALLY-FED  INFANT  256 

GENERAL  ETIOLOGY  AND  PATHOGENESIS 256 

GENERAL  SYMPTOMATOLOGY 262 

CLASSIFICATION 264 

A.  NUTRITIONAL     DISTURBANCES     WITHOUT     Toxic     MANIFESTATIONS 

WITHOUT  DIARRHOEA 265 

DYSTROPHY 265 

NUTRITIONAL  DISTURBANCES  WITHOUT  Toxic  MANIFESTATIONS  WITH 

DIARRHOEA 273 

DECOMPOSITION  (PEDATROPHY) 278 

B.  NUTRITIONAL  DISTURBANCES  WITH  Toxic  MANIFESTATIONS 289 

ACUTE  DYSPEPSIA 289 

INTOXICATION  (ALIMENTARY  TOXICOSIS,  ENTERO-CATARRH,  CHOLERA 

INFANTUM,  ETC 291 

INFECTION  AND  NUTRITION 299 

THE  DISTURBANCES  OF  NUTRITION  OF  BREAST-FED  INFANTS 303 

DISEASES  DUE  TO  ENDOGENOUS  (CONSTITUTIONAL)  CAUSES 305 


xii  CONTENTS 

PAGE 

DISTURBANCES  OF  NUTRITION  OP  OLDER  CHILDREN 307 

ACUTE  DYSPEPSIA  AND  DYSPEPTIC  COMA 307 

CHRONIC  DYSPEPSIA 308 

SEVERE  CHRONIC  DIGESTIVE  INSUFFICIENCY  IN  OLDER  CHILDREN 311 

ACUTE  INFECTIOUS  DISEASES  OF  THE  GASTRO-INTESTINAL  TRACT 314 

DYSENTERY 316 

INTESTINAL  TUBERCULOSIS 320 

INTESTINAL  POLYPOSIS 321 

NERVOUS  GASTRO-INTESTINAL  DISEASES 322 

CONGENITAL  SPASTIC  PYLORIC  STENOSIS 322 

HABITUAL  AND  UNCONTROLLABLE  VOMITING  OF  INFANTS 325 

SIMPLE  PYLOROSPASM 325 

THE  PERIODIC  VOMITING  OF  OLDER  CHILDREN 326 

NERVOUS  VOMITING 327 

NERVOUS  ANOREXIA 328 

OBSTRUCTION  OF  THE  INTESTINAL  CANAL 329 

CONGENITAL  INTESTINAL  STENOSIS 329 

DILATATION  AND  HYPERTROPHY  OF  THE  COLON 330 

HIRSCHSPRUNG'S  DISEASE 330 

CONSTIPATION 331 

INTUSSUSCEPTION - 333 

PROLAPSE  OF  THE  RECTUM 335 

HERNIAS 336 

ENTOZOA 337 

DISEASES  OF  THE  LIVER 339 

CATARRHAL  JAUNDICE 339 

OTHER  FORMS  OF  ACUTE  JAUNDICE 339 

CIRRHOSIS  OF  THE  LIVER 339 

TUMORS  OF  THE  LIVER 340 

CONGENITAL  OBSTRUCTION  OF  THE  BILE  DUCTS 340 

DISEASES  OF  THE  PERITONEUM 341 

PURULENT  PERITONITIS 341 

PERITONITIS  IN  OLDER  CHILDREN  FOLLOWING  APPENDICITIS 341 

OTHER  FORMS  OF  PURULENT  PERITONITIS  IN  OLDER  CHILDREN 342 

TUBERCULOUS  DISEASES  OF  THE  PERITONEUM 34*3 

TUBERCULOSIS    OF  THE    MESENTERIC  AND  RETROPERITONEAL  LYMPH 

NODES 343 

FETAL  PERITONITIS 345 

TUMORS 346 

SECTION  IV.  DISEASES  OF  THE  RESPIRATORY  ORGANS 

by 
PROFESSOR  DR.  CLEMENS  FREIHERR  VON  PIRQUET, 

Director  of  the  University  Children's  Clinic,  Vienna. 

Revised  and  Edited  by 
WALTER  H.  O.  HOFFMANN,  M.  D.,  Chicago,  III., 

Associate  Attending  Pediatrist,  Children's  Memorial  Hospital,  Chicago. 

DISEASES  OF  THE  NOSE 347 

RHINITIS,  CORYZA ]  347 

THE  CLINICAL  SYMPTOMS  OF  ACUTE  RHINITIS '.  350 

CHRONIC  CORYZA 352 

ADENOID  VEGETATIONS 

FOREIGN  BODIES  IN  THE  NOSE • 354 

EPISTAXIS 354 

DISEASES  OF  THE  EUSTACHIAN  TUBES  AND  THE  MIDDLE  EAR .  355 

OTITIS  MEDIA  CATARRHALIS  NEONATORUM .  356 

ACUTE  OTITIS  MEDIA 356 

CHRONIC  OTITIS  MEDIA 359 

FOREIGN  BODIES  IN  THE  EXTERNAL  AUDITORY  CANAL.  .  360 

CONGENITAL  STRIDOR 360 

ACUTE  LARYNGITIS    (PSEUDOCROUP) 361 

FOREIGN  BODIES  IN  THE  BRONCHIAL  TUBES 363 


CONTENTS  xiii 

PAGE 

PAPILLOMA  OF  THE  LARYNX 364 

THE  ACUTE  TRACHEOBRONCHITIS  OF  OLDER  CHILDREN 364 

BRONCHITIS 364 

ASTHMATIC  BRONCHITIS 368 

CAPILLARY  BRONCHITIS 370 

BRONCHO-PNEUMONIA 373 

LOBAR  PNEUMONIA 376 

CHRONIC  PNEUMONIA 381 

EMPHYSEMA 382 

BRONCHIECTASIS 382 

PLEURISY 383 

EMPYEMA 384 

SEROFIBRINOUS  PLEURISY 386 

TREATMENT  OF  SEROUS  PLEURISY 388 

SECTION  V.— DISEASES  OF  THE  HEART 

by 
PROFESSOR  DR.  E.  FEER, 

Director  of  the  University  Children's  Clinic,  Zurich,  Switzerland. 

Revised  and  Edited  by 
HENRIETTA  CALHOUN,  M.  A.,  M.  D.,  Iowa  City,  Iowa, 

Assistant  Professor  of  Pathology,  College  of  Medicine,  State  University  of  Iowa. 

DISEASES  OF  THE  HEART 389 

HEART  MURMURS 391 

NERVOUS  DISTURBANCES 393 

CONGENITAL  HEART  LESIONS 394 

DEFECT  OF  THE  INTERVENTRICULAR  SEPTUM 396 

ROGER'S    DISEASE 396 

PATENCY  OF  THE  DUCTUS  ARTERIOSUS  (BOTALLI) 397 

PULMONARY  STENOSIS 398 

AORTIC  STENOSIS 399 

TRANSPOSITION  OF  THE  GREAT  VESSELS 399 

ACUTE  ENDOCARDITIS 400 

CHRONIC  ENDOCARDITIS  AND  ACQUIRED  VALVULAR  LESIONS 403 

ACUTE  PERICARDITIS 407 

PERICARDIAL  ADHESIONS 411 

MYOCARDITIS  AND  CARDIAC  INSUFFICIENCY 413 

APPENDIX:  BLOOD-VESSELS  AND  JUVENILE  HEART 417 

SECTION  VI.— DISEASES  OF  THE  GENITO-URINARY  TRACT 

by 
PROFESSOR  DR.  C.  NOEGGERATH, 

Director  of  the  University  Children's  Clinic,  Freiburg  in  Breisgau. 

INTRODUCTION 419 

UREMIA 420 

ORTHOTIC  ALBUMINURIA  421 

TUBULAR  NEPHROPATHY  OR  NEPHROSIS 428 

ACUTE   DIFFUSE  GLOMERULAR    NEPHROPATHY,    ACUTE    GLOMERULAR 

NEPHRITIS 431 

GLOMERULO-TUBULAR  NEPHROPATHY  (MIXED  FORM) 434 

KIDNEY  DISEASES  IN  INFANTS 436 

CHRONIC  KIDNEY  DISEASE 436 

CHRONIC  NEPHRITIS  OF  CHILDHOOD  (PEDONEPHRITIS) 437 

NEPHRITIS  WITH  CONGENITAL  SYPHILIS 438 

PURULENT    DISEASES   OF    THE  URINARY  TRACT  AND  THE  KIDNEYS  .  .  .  439 

CYSTOPYELITIS;  PYELONEPHRITIS  AND  RENAL  ABCESSES 439 

DIABETES  INSIPIDUS 445 

ENTJRESIS 446 

VULVO-VAGINITIS 449 

PHIMOSIS,  PARAPHIMOSIS  AND  BALANITIS 452 


X1V  CONTENTS 

PAGE 

HYDROCELE  (SEROUS  PERIORCHITIS) 453 

ANOMALIES  IN  POSITION  OP  THE  TESTES 453 

MASTURBATION 454 

NEW  GROWTHS 455 

SECTION  VII.— DISEASES  OF  THE  NERVOUS  SYSTEM 

by 
PROFESSOR  Da.  JUSSUF  IBRAHIM, 

Director  of  the  University  Children's  Clinic,  Jena. 

ORGANIC  DISEASES  OF  THE  NERVOUS  SYSTEM 457 

I.  DISEASES  OF  THE  MENINGES 

TUBERCULOUS  MENINGITIS 458 

PURULENT  MENINGITIS  (MENINGITIS  SIMPLEX) 465 

MENINGOCOCCUS   MENINGITIS   OR  EPIDEMIC  CEREBRO-SPINAL   MEN- 
INGITIS   i 467 

SEROUS  MENINGITIS 474 

MENINGISM,  HYDROCEPHALOID 476 

THE  MENINGITIS  OF  CONGENITAL  SYPHILIS 476 

SINUS  THROMBOSIS 476 

II.  CHRONIC  HYDROCEPHALUS 477 

EXTERNAL  HYDROCEPHALUS 477 

CHRONIC  INTERNAL  HYDROCEPHALUS 477 

HYDRENCEPHALY 483 

III.  RETARDATION  OF  DEVELOPMENT 483 

GROSS  MALFORMATIONS  OF  THE  BRAIN 483 

MICROCEPHALY 484 

SPINA  BIFIDA  (RACHISCHISIS)  AND  CEPHALOCELE 484 

SPINA  BIFIDA  OCCULTA 486 

HYPERTROPHY  OF  THE  BRAIN 487 

PYRGOCEPHALY,  OXYCEPHALY 487 

CONGENITAL  FUNCTIONAL  DEFECTS  OF  THE  CRANIAL  MOTOR  NERVES.  . . .  488 
CONGENITAL  APLASIA  OF  THE  NUCLEUS;  ABSCENCE  OF  THE  NUCLEUS; 

INFANTILE   NUCLEAR   ATROPHY 488 

CONGENITAL  MUSCULAR  DEFECTS 488 

CONGENITAL  M YATONIA 489 

IV.  DISTURBANCE  OF  THE  CEREBRAL  CIRCULATION 489 

CONCUSSION  OF  THE  BRAIN  (COMMOTIO  CEREBRI) 490 

V.  ACUTE  ENCEPHALITIS 491 

APPENDIX  : 493 

VI.  EPIDEMIC  ENCEPHALITIS  (LETHARGIC  ENCEPHALITIS  EPIDEMIC  POLIOMY- 

ELO-ENCEPHALITIS,    SLEEPING   SlCKNESS) 494 

VII.  BRAIN  ABSCESS,  PURULENT  ENCEPHALITIS 496 

VIII.  CEREBRAL  TUMOR 497 

IX.  CEREBRAL  PARALYSIS  OF  CHILDREN;  INFANTILE  CEREBRAL  PALSY 499 

SPASTIC  INFANTILE  HEMIPLEGIA  AND  DIPLEGIA 499 

SPASTIC   INFANTILE   HEMIPLEGIA;   UNILATERAL  CEREBRAL  PARALYSIS 

OF  CHILDREN 501 

SPASTIC  INFANTILE  DIPLEGIA;  CEREBRAL  DIPLEGIA  OF  CHILDREN 503 

PECULIAR  TYPES    OF  THE  DISEASE 505 

X.  SCLEROSIS  OF  THE  CENTRAL  NERVOUS  SYSTEM 510 

XI.  ACUTE  POLIOMYELITIS;  SPINAL  PARALYSIS  OF  CHILDREN 510 

HEINE-MEDIN'S  DISEASE;  ACUTE  EPIDEMIC  INFANTILE  PARALYSIS...  510 

XII.  DISEASES  OF  THE  SPINAL  CORD 521 

MYELITIS 521 

TABES  DORSALIS 521 

TUMORS  OF  THE  CORD 521 

XIII.  ENDOGENOUS  OR  HEREDITO-FAMILIAL  DISEASES  OF  THE  NERVOUS  AND  MUS- 
CULAR SYSTEMS 522 

AMAUROTIC  FAMILIAL  IDIOCY  (T  AY-SACHS'  IDIOCY) 523 

JUVENILE  AMAUROTIC  FAMILIAL  IDIOCY 523 

FAMILIAL  CEREBRAL  DIPLEGIAS  AND  FORMS  OF  CEREBROSPINAL  DISEASE  524 

DISEASES  OF  THE  MYOSTATIC  SYSTEM 524 

HEREDITARY  ATAXIA  (FRIEDREICH'S  ATAXIA) 525 


CONTENTS  xv 

PAGE 

MUSCULAR  ATROPHIES 526 

UNCOMMON  FORMS 528 

XIV.   DISEASES  OF  THE  PERIPHERAL  NERVOUS  SYSTEM 528 

PARALYSES 528 

NEURALGIA 529 

POLYNEURITIS 529 

XV.  DISEASES  OP  THE  MUSCLES 529 

FUNCTIONAL  DISEASES  OF  THE  NERVOUS  SYSTEM 530 

I.  CONVULSIVE  DISEASES . '. 530 

SPASMOPHILIA  OR  SPASMOPHILIC  DIATHESIS 530 

LARYNGOSPASM,  TETANY  AND  ECLAMPSIA 530 

ECLAMPSIA  DUE  TO  NON-SPASMOPHILIC  CAUSES 541 

GENERAL  MUSCULAR  HYPERTONIA,  WITHOUT  SPASMOPHILIA 543 

NUTANT  AND  ROTATORY  SPASMS 543 

PSEUDOTETANUS  544 

EPILEPSY 545 

II.  CHOREA  MINOR  (ST.  VITUS  DANCE) 549 

PARAMYOCLONUS  MULTIPLEX;  CHOREA  ELECTRICA 553 

III.  NEUROPATHIC  AND  PSYCHOPATHIC  CONSTITUTION 553 

HEREDITARY  NEUROPATHY 553 

MIGRAINE:  HEMICRANIA 556 

MALADIE  DBS  TICS  CONVULSIFS 556 

EMOTIONAL  RESPIRATORY  CONVULSIONS:  ABSENCES 557 

PATHOLOGIC  REFLEXES 558 

PAVOR  NOCTURNUS 558 

NEURASTHENIA 559 

PHOBIAS;  UNCONTROLLABLE  IDEAS  AND  ACTS 561 

DISTURBANCES  OF  PSYCHICAL  IMPULSES 562 

HYSTERIA 562 

IV.  PSYCHOSES 567 

CONGENITAL  AND  EARLY  ACQUIRED  DEFECT  PSYCHOSES  (FEEBLE  MIND- 

EDNESS,  IDIOCY;  IMBECILITY,  MENTAL  DEBILITY) •    ....  567 

ACQUIRED  DEFECT  PSYCHOSES 569 

HEBEPHRENIA:  CATATONIA  OR  DEMENTIA  Pn^cox 570 

PSYCHOSES  WITHOUT  DEFECTS  OF  INTELLIGENCE 570 

SECTION  VIII.  THE  ACUTE  INFECTIOUS  DISEASES 

by 
PROFESSOR  DR.  E.  FEER, 

Director  of  the  University  Children's  Clinic,  Zurich. 

Revised  and  Edited  by 
E.  C.  FLEISCHNER,  M.  D.,  San  Francisco,  Calif., 

Clinical  Professor  of  Pediatrics,  University  of  California, 

and 
K.  F.  MEYER,  M.  D.,  San  Francisco,  Calif., 

Professor  of  Research  Medicine,  University  of  California. 

GENERAL  CONSIDERATION 571 

SCARLET  FEVER 579 

PECULIARITIES,  SEQUELAE  AND  COMPLICATIONS  OF  SCARLET  FEVER 588 

MEASLES  (MORBILLI) 598 

RUBELLA  (GERMAN  MEASLES  ROTELN) 616 

INFECTIOUS  ERYTHEMA 620 

DUKE'S  "FOURTH"  DISEASE 622 

VARICELLA  (CHICKEN-POX)  623 

PECULIARITIES  OF  THE  EXANTKEM 626 

VACCINATION  (Cow-pox) 630 

PECULIARITIES  OF  COURSE  AND  COMPLICATIONS 634 

DIPHTHERIA 637 

PATHOGENESIS  AND  PATHOLOGIC  ANATOMY 641 

THE  GENERAL  DISEASE-PICTURE 642 

MILD  FORMS 644 

SEVERE  FORMS  . .  645 


xvi  CONTENTS 

PAGE 

SPECIAL  LOCALIZATIONS  OF  DIPHTHERITIC  MEMBRANES 646 

NASAL  DIPHTHERIA 647 

AURAL  DIPHTHERIA 648 

DIPHTHERIA  OF  THE  LARYNX,  TRACHEA  AND  BRONCHI 648 

RARE  LOCALIZATIONS  OF  DIPHTHERIA 651 

PECULIARITIES  OF  DIPHTHERITIC  MEMBRANES 652 

THE  EFFECT  OF  DIPHTHERIA  ON  VARIOUS  ORGANS 653 

COMPLICATIONS  AND  SEQUELS 653 

THE  DIAGNOSIS  OF  DIPHTHERIA 656 

DIFFERENTIAL  DIAGNOSIS 656 

DIFFERENTIAL  DIAGNOSIS  OF  AFFECTIONS  OF  THE  LARYNX 657 

PERTUSSIS  OR  WHOOPING-COUGH 672 

VARIATIONS  IN  COURSE 675 

SPECIAL  SYMPTOMS  AND  COMPLICATIONS 676 

MUMPS    (EPIDEMIC  PAROTITIS) 684 

TYPHOID  FEVER 688 

PECULIARITIES  OF  COURSE;  COMPLICATIONS 692 

PARATYPHOID 698 

INFLUENZA  AND  GRIPPAL  DISEASES 699 

ACUTE  ARTICULAR  RHEUMATISM  (POLYARTHRITIS  ACUTA) 706 

PECULIARITIES  OF  THE  COURSE  WITH  IMPLICATIONS  OF  VARIOUS  ORGANS  .  708 

CHRONIC  RHEUMATISM 711 

ERYSIPELAS 713 

GENERAL  SEPSIS 715 

SECTION  IX.  TUBERCULOSIS 

by 

PROFESSOR  DR.  CLEMENS  FREIHERR  VON  PIRQUET,  , 

Director  of  the  University  Children's  Clinic,  Vienna. 

Revised  and  Edited  by 
HENRY  DIETRICH,  M.  D.,  Los  Angeles,  Calif. 

Attending  Pediatrician,  Children's  Hospital,  Los  Angeles. 

TUBERCULOSIS 720 

CLINICAL  MANIFESTATIONS  725 

PRIMARY  STAGE 725 

TUBERCULOSIS  OF  THE  BRONCHIAL  LYMPH  NODES 726 

PRIMARY  TUBERCULOSIS  OF  THE  LUNGS 727 

THE  SECONDARY  STAGES;  OR  THE  GENERAL  SPREAD  OF  TUBERCULOSIS.   728 

SCROFULA 739 

CHRONIC  PULMONARY  TUBERCULOSIS;  THE  TERTIARY  STAGE 735 

SECTION  X.  SYPHILIS 

by 
PROFESSOR  DR.  ERNST  MORO, 

Director  of  the  University  Children's  Clinic,  Heidelberg. 

Revised  and  Edited  by 
PHILIP  C.  JEANS,  M.  D.,  St.  Louis,  Mo., 

Associate  Professor  of  Pediatrics,  Washington  University  School  of  Medicine. 

ETIOLOGY  AND  NATURE 750 

MODES  OF  INFECTION 752 

CONGENITAL  SYPHILIS .   754 

FETAL  SYPHILIS 755 

INFANTILE  SYPHILIS \  757 

RECURRENCES  IN  EARLY  CHILDHOOD .   774 

LATE  CONGENITAL  SYPHILIS: 775 

THE  DIAGNOSIS  OF  CONGENITAL  SYPHILIS  ....  777 

PROGNOSIS [  781 

THE  TREATMENT  OF  CONGENITAL  SYPHILIS '.  782 

ACQUIRED  SYPHILIS  IN  CHILDREN 785 


CONTENTS  xvii 

PAGE 

SECTION  XI.  DISEASES  OF  THE  SKIN 

by 
PROFESSOR  DR.  ERNST  MORO, 

Director  of  the  University  Children's  Clinic,  Heidelberg. 

Revised  and  Edited  by 
HARRY  GARFIELD  IRVINE,  M.  D.,  Minneapolis,  Minn. 

INTRODUCTION. 787 

ECZEMA 791 

INTERTRIGINOUS  ECZEMA 793 

ERYTHRODERMIA 795 

CONSTITUTIONAL  ECZEMA  OF  INFANTS 796 

URTICARIA 803 

SIMPLE  URTICARIA 804 

ACUTE  CIRCUMSCRIBED  EDEMA  OF  THE  SKIN  (GIANT  URTICARIA) 805 

STROPHULUS 805 

PRURIGO 807 

MULTIPLE  ERYTHEMA  (ERYTHEMA  MULTIFORME) 809 

IMPETIGO 811 

IMPETIGO  CONTAGIOSA 811 

PEMPHIGUS  NEONATORUM 812 

DERMATITIS  EXFOLIATIVA 813 

FURUNCULOSIS 814 

PARASITIC  SKIN  DISEASES 815 

PEDICULOSIS 815 

SCABIES 816 

TUBERCULOSIS 818 

LUPUS 819 

SCROFULODERMA 821 

LICHEN,  ACNE,  ECZEMA 822 

THE  SMALL  PAPULAR  TUBERCULIDE  OF  INFANCY 824 

THE  PAPULO-NECROTIC  TUBERCULIDE 824 

SUPPLEMENT 

EXUDATIVE  DERMATOSIS 825 

URTICARIA  PIGMENTOSA  (XANTHELASMOIDEA) 825 

HERPES  SIMPLEX  (HERPES  FEBRILIS,  HERPES  LABIALIS,  COLD  SORES, 

FEVER  BLISTERS) 826 

HERPES  ZOSTER  (ZONA  SHINGLES) 827 

PEMPHIGUS 827 

PEMPHIGUS  ACUTUS 828 

PEMPHIGUS  FOLIACEUS 828 

PEMPHIGUS  VEGETANS 828 

PEMPHIGUS  VULGARIS 828 

EPIDERMOLYSIS  BULLOSA 829 

HYDROA  VACCINIFORME 829 

INFLAMMATIONS  OF  THE  SKIN 830 

DERMATITIS  VENENATA 830 

DRY  SCALY  INFLAMMATORY  DERMATOSES 831 

PlTYRIASIS    ROSEA     (HERPES    TONSURANS   MACULOSUS,    PlTYRIASIS 

CIRCINATA) 831 

PSORIASIS 832 

INFECTIOUS  DISEASES  OF  THE  SKIN 834 

GRANULOMA  PYOGENICUM 834 

FAVUS  (TINEA  FAVOSA) 834 

TINEA  TRICHOPHYTINA  (RINGWORM,  TRYCHOPHYTOSIS) 835 

TINEA  TRICHOPHYTINA  CORPORIS  (TINEA   CIRCINATA:  RINGWORM 

OF  THE  BODY;  TRICHOPHYTOSIS  CORPORIS.) 835 

TINEA  TRICHOPHYTINA  CRURIS  (TINEA  CRURIS;  ECZEMA  MARGI- 

NATUM;  DHOBIE  ITCH) 836 

ONYCHOMYCOSIS  (RINGWORM  OF  THE  NAILS) 837 

TINEA  TRICHOPHYTON  CAPITIS  (TINEA  CAPITIS:  TINEA  TONSURANS: 
RINGWORM  OP  THE  SCALP) 837 


xviii  CONTENTS 

PAGE 

DISEASES  OP  THE  APPENDAGES  OF  THE  SKIN 839 

MILIARIA 839 

MILIUM  (STROPHULUS  ALBIDUS,  ACNE  ALBIDA) 840 

COMEDO 840 

GROUPED  COMEDONES  IN  CHILDREN 840 

ACNE  NEONATORUM - 840 

ACNE  VULGARIS 840 

ALOPECIA  AREATA 841 

BENIGN  EPITHELIAL  GROWTHS 842 

ADENOMA  SEBACEUM 842 

HYPERTROPHIES 843 

VERRUCA  VULGARIS 843 

VERRUCA  PLAN^E  JUVENILIS 843 

KERATODERMIA  PALMARIS  ET  PLANTARTS   (SYMMETRICAL    KERATO- 
DERMIA  OF  THE  EXTREMITIES,  CONGENITAL  KERATOMA  OF  THE 

PALMS  AND  SOLES,  ICHTHYOSIS,  PALMARIS  ET  PLANTARIS) 844 

ICHTHYOSIS  (XERODERMA,  FISHSKIN  DISEASE) 844 

ATROPHIES 847 

XERODERMA  PIGMENTOSUM 847 

DEGENERATIVE  NEOPLASMATA 848 

MOLLUSCUM  CONTAGIOSUM  (MOLLUSCUM  SEBACEUM,   EPITHELIOMA 

CONTAGIOSUM) 848 

XANTHOMA  (FIBROMA   LIPOMATODES,    XANTHELASMA)   849 

NEVUS  (BIRTH-MARK) : 849 

NEVUS  PlGMENTOSUS  (PlGMENTED  MOLE) 849 

NEVUS  VASCTTLOSUS  (NEVUS  SANGUINEUS,  NEVUS  FLAMMEUS,  MOTHS 

MARK,  BIRTH-MARK,  PORT-WINE-MARK) 851 

TELANGIECTASIS .  852 


GENERAL  CONSIDERATIONS 

BY 
MARTIN  THIEMICH,  LEIPZIG. 


I.  ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES 

REVISED  BY 
Dr.  RICHARD  EVERINGHAM  SCAMMON, 

Professor  of  Anatomy,  University  of  Minnesota  Medical  School,  Minneapolis. 

THE  new-born  infant  is,  by  no  means,  to  be  considered  a  miniature  of  the 
adult.  While  obvious  differences  are  shown  externally  in  the  relatively 
large  head  and  small  face,  the  short  extremities,  the  notable  arching  of  the 
thoracic  walls,  the  undeveloped  genitalia,  etc;  numerous  other  differences  in 
anatomic  and  histologic  structure  and  in  the  physiologic  functions  of  the 
various  organs  and  systems  of  organs  are  discoverable  by  careful  study. 
Certain  of  these,  of  especial  interest  to  the  physician,  will  be  described. 
Those  which  are  merely  of  anatomic  interest,  or  useful  in  the  study  of  cases 
which  come  to  autopsy  will  be  specifically  noted  in  Chapter  III. 

The  body  of  the  child  contains  more  water  than  that  of  the  adult;  the 
largest  percentage  is  found  in  the  fetus;  the  proportion  decreases  rapidly 
toward  puberty.  The  body  of  the  new-born  contains  about  25  per  cent, 
of  solids  and  that  of  the  adult  about  33  per  cent.  Under  normal  conditions, 
an  increased  water  content  of  the  infant  body  causes  a  correspondingly 
increased  turgor  or  sense  of  resistance  of  the  skin  and  subcutaneous  tissues. 

Among  the  differences  described  in  the  chemical  composition  of  the 
entire  organism,  special  attention  may  be  called  to  one  item.  In  the  last 
months  of  fetal  life,  a  considerable  deposit  of  iron  salts  is  gathered  in  the 
liver,  enabling  the  infant  to  exist  for  a  varying  length  of  tune  upon  a  diet  as 
poor  in  iron  as  mother's  or  cow's  milk,  without  lack  of  this  essential  material 
for  the  purpose  of  blood  metabolism. 

The  Anatomic  and  Hemodynamic  Relations  of  the  Heart. — These  show 
great  departures  from  adult  life.  The  absolute  weight  of  the  heart  in  the 
new-born  averages  about  20-25  grams,  about  one-twelfth  the  adult  weight  of 
the  organ.  At  birth  the  organ  forms  about  0.7  per  cent,  of  the  body-weight 
compared  to  about  0.4  to  0.6  per  cent,  of  the  body-weight  in  the  nursling. 
The  relative  or  percentage  weight  of  the  heart  usually  falls  to  about  0.5  per 
cent,  during  the  first  year.  The  weights  of  the  musculature  of  the  right 
and  the  left  ventricle  is  usually  about  equal  at  birth,  but  the  left  ventricle  is 
double  the  weight  of  the  right  by  the  close  of  the  first  six  months.  The  wall 
of  the  left  ventricle  is  only  slightly  thicker  than  that  of  the  right;  and  the 
heart,  with  its  large,  wide  ventricles,  has  a  much  lower  resistance  to  work 

1 


2  TEXT-BOOK  OF  PEDIATRICS 

against  because  of  the  relatively  large  lumen  and  the  larger  sectional  area 
of  the  arteries.  This  is  shown  by  the  systolic  pressure,  which  is  80-90  mm. 
of  mercury  in  the  infant  and  110-120  mm.  in  the  adult.  The  pulse  is  more 
frequent,  ranging  from  134  during  the  first  year  of  life,  and  gradually  de- 
creasing in  rate  to  about  90  during  the  eighth  or  ninth  years.  It  is  more 
elastic  and  compressible.  The  complete  circuit  of  the  blood  is  more  rapid 
than  in  the  adult.  When  one  considers  that  neither  the  heart  muscle  nor 
the  arterial  walls  have  been  injured  by  the  insidious  poisoning  of  tobacco 
and  alcohol,  or  by  chronic  and  recurring  infections,  and  that  arterio- 
sclerosis is  a  condition  almost  unknown  in  childhood,  it  may  be  readily 
understood  that  the  vascular  system  can  withstand  the  severest  demands 
upon  it  and  can  compensate  serious  obstructions  to  the  circulation  for  a 
long  time.  However,  for  a  time,  during  the  development  of  puberty, 
the  heart  does  not  keep  pace  with  the  rapid  growth  of  the  body 
and  changes  in  its  anatomic  relations  may  cause  functional  lesions  or 
cardiac  insufficiencies. 

During  the  first  few  days  of  life,  the  period  in  which  the  physiologic 
loss  of  weight,  due  to  the  output  of  large  quantities  of  fluid  occurs,  the 
blood  has  a  relatively  higher  percentage  of  haemoglobin,  an  increased  num- 
ber of  cells  and  a  higher  specific  gravity.  This  concentration  disappears 
during  the  first  month,  and  after  that  a  very  gradual  decrease  in  the  per- 
centage of  haemoglobin,  in  the  relative  number  of  erythocytes  and  in  the 
slight  leucocytosis  continues,  until,  by  the  end  of  the  second  year,  the 
blood  of  the  child  is  the  same  as  that  of  the  adult.  It  may  be  questioned 
whether  the  concentration  of  the  blood  through  the  loss  of  fluids  from  the 
body  is  the  main  cause  of  the  natal  leucocytosis  since  the  number  of  cells 
drops  rapidly  in  the  second  and  third  days  after  birth  while  the  body  is  still 
losing  in  weight.  A  slight  secondary  rise  in  the  white  cell  count  is  often 
noted  in  the  second  week  coincident  with  the  detachment  of  the  umbilical 
cord.  In  general  the  total  leucocyte  count  after  this  time  is  little  higher  in 
the  infant  than  in  the  adult.  The  lymphocytes  form  from  30  to  40  per  cent. 
of  all  leucocytes  in  the  first  year  and  the  polymorphonuclear  neutrophiles 
form  50  to  60  per  cent.  From  this  time  on  the  neutrophiles  increase  and 
the  lymphocytes  decrease  in  relative  numbers.  Their  percentages  are  about 
equal  (at  about  45  per  cent.)  at  five  to  six  years.  The  counts  of  eosino- 
philic  and  basophilic  leucocytes  and  of  transitional  cells  are  about  the  same 
in  infancy,  childhood  and  maturity.  The  blood  does  not  assume  its  normal 
adult  picture  until  about  the  time  of  puberty.  During  the  years  of  infancy, 
however,  the  leucocytes  remain  slightly  increased  and  a  peculiarity  in  the 
percentage  of  their  various  forms  is  maintained  to  the  end  of  childhood;  the 
lymphocytes  representing  50  per  cent.,  while,  later,  they  decrease  to  about 
25  per  cent.  During  the  first  two  weeks  of  life,  the  normal  hoemoglobin 
content  is  about  36  per  cent,  greater  than  in  the  adult.  From  these  high 
values,  the  percentage  begins  to  diminish  at  once  and,  after  two  weeks,  the 
fall  is  very  rapid.  By  the  fifth  month  the  value  reaches  very  nearly  the 
minimum  and  is  far  below  the  value  of  adult  life. 

The  respiratory  apparatus  and  its  mechanics  present  important  differ- 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES  3 

ences.  The  thorax  of  the  new-born,  with  its  high  arch  and  its  lesser  length, 
is  always  in  the  phase  of  almost  extreme  inspiration,  the  ribs  forming 
nearly  a  right  angle  with  the  vertebral  column.  As  a  result,  the  breathing 
is  almost  entirely  abdominal  or  diaphragmatic.  To  compensate  for  the 
shallowness  of  the  respiration,  its  frequency  is  increased  and  every  added 
demand  upon  the  respiratory  function  of  pathologic  origin  produces  an 
increase  in  the  number  of  respirations.  As  the  child  grows  older  and  is  not 
continuously  recumbent,  the  upright  position  causes  a  gradual  change  in  the 
form  of  the  chest  which  makes  thoracic  breathing  possible.  The  weight  of 
the  abdominal  organs  and  of  the  thoracic  walls  in  the  vertical  position  tend 
to  draw  down  the  anterior  wall  of  the  thorax.  The  larger  air  passages, 
larynx,  trachea  and  bronchi,  are  also  affected  by  the  downward  stress. 
The  ribs,  which  were  initially  transverse  to  the  vertebral  column,  not  only 
take  an  obliquely  downward  position  but  also  change  shape  by  the  formation 
of  a  distinct  angle,  which  increases  the  thoracic  space  and  gives  more  room 
for  the  lungs,  both  anteroposteriorly  and  laterally.  The  ultimate  results  of 
these  anatomic  changes  upon  functional  activity  are  seen  in  the  gradual 
assumption  of  the  mixed  type  of  breathing  (thoracic  and  diaphragmatic) 
in  the  increased  volume  of  the  respiration  and  in  the  reduced  frequency  of 
its  rhythm. 

These  changes  are  completed  at  about  the  end  of  the  first  year,  at  which 
time  the  number  of  the  respirations  has  been  reduced  from  40  or  45  per 
minute,  at  birth,  to  25.  The  respiratory  volume  ranges  from  27  to  42  c.c. 
during  the  first  six  months  of  life;  while  it  increases  to  78  c.c.  during  the 
second  six  months  and  to  135  c.c.  by  the  end  of  the  first  year  (Gregor). 

Later,  the  number  of  respirations  is  reduced  very  gradually,  so  that  the 
average,  during  rest  and  sleep,  at  two  years  of  age,  is  about  24  per  minute, 
at  five  years  about  20  per  minute,  and  at  ten  years  about  18  per  minute. 
The  individual  respirations  grow  deeper,  the  mechanism  works  more  eco- 
nomically and  is  readily  able  to  overcome  temporary  demands  for 
increased  activity  by  its.  greater  elasticity,  indicated  both  in  frequency 
and  volume. 

Attention  should  also  be  called  to  the  fact  that  the  respiratory  rhythm, 
during  the  first  months  of  life,  and,  at  times,  even  up  to  the  third  year,  is 
not  always  regular.  In  the  young  infant,  pauses  of  varying  length  may 
occur  (Czerny).  The  differences  in  respiration,  dependent  upon  sex,  the 
thoracic  type  of  the  female  and  the  abdominal  type  of  the  male,  do  not 
make  their  appearance  until  after  the  tenth  year.  More  or  less  permanent 
malformations  of  the  thoracic  wall  may  occur  in  infants  as  a  result  of 
pathologic  conditions,  such  as  forced  respiration  and  an  abnormal  softness 
of  the  ribs.  These  may  be  due  in  part  to  an  incurvation  of  the  thoracic 
wall  at  the  attachment  of  the  diaphragm. 

THE  PHYSIOLOGY  OF  NUTRITION 

The  knowledge  of  the  physiology  of  nutrition  is  of  great  importance  in 
the  understanding  of  the  pathology  of  childhood.  Because  milk  is  the  chief 
article  of  diet,  during  the  first  year  we  incline  to  classify  the  descrip- 


4  TEXT-BOOK  OF  PEDIATRICS 

tion  of  the  digestive  processes  according  to  the  kinds  of  milk  in  common 
use.  Practically,  it  is  necessary  to  consider,  in  addition  to  the  human  milk, 
only  that  of  the  cow  and  goat.  Asses'  milk,  with  its  very  low  fat  content, 
is  hard  to  get  and  not  indispensable. 

In  the  following  table1  the  more  important  constituents  and  peculiar- 
ities of  woman's,  cow's  and  goat's  milk  are  arranged  for  ready  comparison 
and  as  a  basis  for  discussion. 

PERCENTAGE  COMPOSITION  AND  PECULIARITIES  OF  MILK. 


Woman's 

Cow's 

Goat's 

Water                                     

87 

88 

87 

Solids                                         

13 

12 

13 

Total  nitrogen                             

0.15-0.30 

0.55 

0.56 

Nitrogen  in  protein  

0.12-0.17 

0.5 

0.43 

Total  protein                   

1.0  -1.5 

3.0-4.0 

3.5 

Caseinogen                            

0.6  -1.0 

3.0 

3.8 

Lactalbumin  and  globulin        

0.5 

0.3 

1.2 

Lactose                     

7.0 

4.0-4.5 

4.4 

Fat                                    

4.0 

3.0-4.0 

4.0 

Total  ash  

(1.3-9.0) 
0.14-0.28 

0.7 

0.7-1.0 

Calcium  oxide  

0.03 

0.2 

0.2 

Phosphorus  pentoxide  

0.05 

0.24 

0.28 

Iron  oxide              .                

0.0005 

0.001* 

0.003 

Chlorine  

0.043 

0.1 

0.1 

Heat  value   (calories  per  litre) 

650-750 

650-750 

Reaction  to  htm  us  

alkalin 

amphoteric 

amphoteric 

Combining  power  (acidity),  per  litre 
with  blue  litmus  in  N/10  acid. 

85 

320-550 

*  According  to  more  recent  estimations,  only  a  part  of  this  iron  is  actually  a  constit- 
uent of  cow's  milk.  The  greater  part  comes  from  the  utensils  of  transportation,  etc. 

The  total  nitrogen  consists  largely  of  the  nitrogen  of  the  caseinogen, 
lactalbumins  and  lactoglobulins.  A  small  fraction  is  found  in  ammonia  and 
in  extractives,  which  are  probably  excretion  products  of  the  lacteal  gland; 
some  may  also  be  found  in  the  questionable  lactomucins.  The  caseinogen, 
or  more  properly  the  caseinogens,  because  we  have  to  deal  with  different 
substances  in  the  various  kinds  of  milk,  are  acid  protein  bodies  containing 
phosphorus.  They  are  insoluble  in  water,  but  dissolve  in  acids,  bases  and 
salt  solutions;  and  are  held  in  solution  or  in  an  ultramicroscopically  fine 
colloidal  suspension  in  the  milk  by  alkalis  or,  more  properly,  by  alkalin 
earths.  The  lactalbumins  and  lactoglobulins  are  usually  called  soluble  pro- 
teins, in  contradistinction  to  the  caseinogen  which  is  called  an  insoluble 
protein.  Clinically,  great  stress  has  been  laid  for  a  long  while  upon  this 
difference,  because  the  less  digestible  cow's  milk  actually  and  relatively 
contains  more  caseinogen  than  human  milk.  At  first,  it  appeared  that  the 
greater  digestibility  of  human  milk  was  due  to  the  presence  of  larger  amounts 


1  This,  table,  with  a  few  minor  changes,  is  taken  from  the  chapter  on  milk  by 
Raudnitz,  in  Pfaundler  and  Schlossmann's  Treatise  of  Pediatrics.  2nd  Edition,  1910, 
Vol.  1.,  pp.  133. 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES  5 

of  the  soluble  protein,  as  well  as  to  the  demonstrated  differences  in  the  two 
caseins.  When  coagulated  by  acid  or  by  the  action  of  ferments,  to  the  oper- 
ation of  which  the  presence  of  calcium  salts  is  necessary,  the  caseinogen  of 
cow's  milk  forms  a  more  solid  and  a  coarser  curd  than  that  of  human  milk; 
and,  upon  digestion  in  vitro  with  pepsin  and  hydrochloric  acid,  leaves  a 
residue  of  "  pseudonuclein, "  sparingly  soluble  and  digested  only  after  a 
long  time  and  with  great  difficulty.  This  is  not  found  in  human  milk. 
The  facts,  later  to  be  discussed  more  fully,  that  the  direct  absorption  of 
lactalbumin  and  lactoglobulin,  formerly  accepted  as  a  fact,  has  been  proved 
an  error,  and  that  the  appearance  in  the  intestine  of  this  undigested 
"pseudonuclein"  has  no  pathogenic  significance,  have  limited  the  value 
of  these  findings. 

Milk-sugar,  of  which  human  milk  contains  a  larger  percentage  than 
either  cow's  or  goat's  milk,  is  chemically  the  same  substance  in  the 
three  varieties. 

This  is  not  true  of  the  milk  fats  which  represent  complicated  mixtures 
of  various  glycerin  esters  and  free  fatty  acids.  They  are  inconstant  in 
their  composition  and  are  dependent,  to  a  certain  extent,  upon  the  fats 
of  the  food  digested  by  the  milk-producer.  Cow's  milk  contains,  in  round 
numbers,  four  times  as  much  volatile  fatty  acid  as  does  human  milk. 

The  fat  content  (see  table)  shows  greater  minimal  and  maximal  vari- 
ations than  any  other  constituent.  Apart  from  individual  differences, 
found  alike  in  human  and  in  animal  milk,  we  note  that  in  both  the  first 
portion  of  the  milk  extracted  from  the  organ  contains  a  smaller  percentage 
of  fat  than  does  the  later  output,  and  that  the  fat  content  increases  pro- 
portionately and  gradually  as  the  gland  is  emptied;  showing  the  most 
gradual  increase  in  breasts  which  secrete  large  quantities.  The  average 
percentage  of  fat  content  is  therefore  smaller  in  milk  obtained  from  a  freely 
secreting  organ  than  from  one  which  secretes  less. 

The  various  mineral  constituents  shown  in  the  ash  receive  much  atten- 
tion at  present.  In  part,  these  constituents  are  found  in  the  organic  com- 
ponents of  the  milk  and  especially  in  the  protein  bodies,  in  the  molecules  of 
which  they  are  incorporated  with  greater  or  less  stability;  and,  in  part,  they 
are  found  as  certain  preformed  salts  in  diffusible  and  more  or  less  ionized 
state  in  solution  in  the  whey. 

The  quantity  of  mineral  constituents  is  much  greater  in  animal  milk 
than  in  human  milk,  corresponding  to  the  greater  demand  which  the  more 
rapid  growth  of  the  young  animal  makes.  This  is  especially  true  of  calcium 
and  phosphorus,  the  two  important  inorganic  constituents  of  bone.  It  is 
interesting  to  note  that  both  human  and  animal  milk  are  comparatively 
poor  in  chlorine.  The  mineral  content  of  the  ash  of  human  milk  has  not  the 
same  relation  to  the  body-ash  of  the  new-born,  as  von  Bunge  has  found  to 
be  true  of  the  milk  and  body-ash  of  several  very  rapidly  growing  animals. 
It  is  adequate,  however,  with  probably  the  single  exception  of  its  iron  con- 
tent, to  the  normal  nutritive  demands  of  growth  and  repair  and  of  functional 
development  in  all  the  infantile  organs. 

The  reaction  of  fresh  milk  to  litmus  is  amphoteric  or  alkalin.     Upon 


6  TEXT-BOOK  OF  PEDIATRICS 

standing,  the  ensuing  bacterial  action  ferments  the  milk-sugar  and  pro- 
duces acid.  This  is  of  great  importance  in  milk  intended  for  infant  feeding 
and  will,  therefore,  be  discussed  further  in  the  chapter  upon  that  subject. 

The  tendency  of  cow's  milk  to  sour  is  twice  as  great  as  that  of  human 
milk.  This  is  of  major  importance  in  the  process  of  gastric  digestion,  for 
with  cow's  milk  a  much  greater  proportion  of  the  hydrochloric  acid  secreted 
by  the  stomach  is  changed  into  combined  form  and  the  appearance  of  free 
hydrochloric  acid  may  be  greatly  delayed  or  may  entirely  fail.  While 
acid  cells  are  found  in  the  gastric  glands  both  of  the  fetus  and  the 
new-born  it  is  approximately  two  years  before  they  reach  their  full  develop- 
ment. The  gastric  mucosa  of  the  infant  is  relatively  thick  and  the  mus- 
cular coat  relatively  thin,  although  all  the  layers  of  the  latter  are  present. 
The  elastic  tissue  of  the  stomach  is  limited  to  the  walls  of  the  arteries  of  the 
organ  for  some  time  after  birth. 

To  the  constant  constituents  of  milk  belong,  in  varying  quantity, 
various  ferments  and  certain  immune  bodies.  The  former  have  long  been 
considered  important  to  the  process  of  digestion  in  the  gastro-intestinal 
tract,  while  the  latter  have  been  supposed  to  be  important  factors  in  the 
development  of  the  high  grades  of  immunity  which  appear  with  the  use  of 
certain  kinds  of  food.  This  view,  on  first  consideration  a  very  essential 
one,  and  chiefly  because  the  usual  practice  of  boiling  milk  for  a  short  time, 
kills  these  ferments  and  immune  bodies,  but  without  affecting  the  food- 
value  of  the  milk,  does  not  seem  tenable  today. 

Neither  human  milk  nor  cow's  milk  has  the  same  composition  at  the 
beginning  of  lactation  as  it  has  when  the  function  is  fully  established,  save 
for  relatively  minor  changes,  it  then  becomes  constant  and  remains  so 
throughout  the  period. 

The  colostrum  is  the  initial  secretion  of  the  functionating  mammary 
gland;  it  is,  at  first,  small  in  quantity,  but  gradually  increases.  It  is  a 
yellow  fluid,  viscid  because  of  its  high  protein  and  globulin  content,  and 
coagulates  upon  heating.  It  contains  about  3  to  5  per  cent,  of  milk 
sugar;  its  fat  content  varies  within  wide  limits.  The  fat  is  not  chemically 
identical  with  the  fat  of  the  later  milk  of  the  same  animal.  In  the  woman, 
the  transition  from  colostrum  to  milk  is  normally  complete  by  the  end  of  the 
first  week. 

The  best  evidence  of  the  colostral  condition  of  the  milk  is  the  discovery 
of  colostral  corpuscles  (see  Fig.  1)  that  is,  of  leucocytes  loaded  with  coarse 
and  fine  fat  droplets,  which  are,  at  first,  very  numerous  in  each  microscopic 
field,  but  later  are  few  and  require  careful  search.  Czerny  has  shown  that 
they  are  leucocytes  and,  according  to  more  recent  investigation  upon  the 
human  subject,  are  lymphocytes  which  take  care  of  the  unchanged,  non- 
absorbable  fat,  present  in  the  temporary  hypersecretion  of  the  mammary 
gland,  by  emulsifying  it  and  removing  it  through  the  lymph  channels, 
They  are  found  whenever  there  is  congestion  of  the  gland  and  to  this  fact 
attaches  their  clinical  interest. 

Since  the  milk  of  animals  is  not  used  directly  from  the  udder,  but  is 
usually  pasteurized  or  sterilized  and  is  variably  diluted  for  infant  use,  it  is 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES  7 

necessary  to  consider,  from  the  viewpoint  of  clinical  interest,  the  physical 
and  chemical  changes  which  follow. 

Dilution  produces  a  slower  coagulation  and  a  finer  curd.  Heating, 
and  the  effect  is  the  same  whether  milk  be  heated  to  70-80°  C.  (150°-180°  F.), 
for  a  long  time,  or  brought  to  the  boiling  point  for  a  short  time — causes  a 
partial  precipitation  of  the  phosphates  or  alkalin  earths  and  the  formation 
of  insoluble  tri  calcium  citrate,  which  delays  clotting,  a  process  dependent 
upon  the  presence  of  soluble  calcium  salts,  and  thus  forms  a  finer  curd. 
Lactalbumin  is  partially  coagulated  at  55°  C.  (140°  F.)  but  is  not  completely 
precipitated  by  boiling,  a  part  being  held  in  solution  by  the  caseinogen  and 
alkalin  salts.  A  portion  of  the  caseinogen  is  dissociated  into  casein  and  its 


FIG.  I. — Fat  globules;  above,  in  mother's  milk;  below,  in  colostrum. 

base,  which  causes  the  formation  of  the  skin  or  pellicle  upon  the  surface  of 
boiled  milk.  The  milk-sugar  is  changed  into  caramel  by  continued  boiling 
and  the  brown  color  of  commercial  preparations  which  have  been  excessively 
sterilized  is  due  to  a  reaction  between  the  milk-sugar  and  the  caseinogen. 
Similarly,  long  continued  heating  causes  a  coalescence  of  the  fat  globules. 
The  inorganic  constituents  are  greatly  changed  upon  boiling  by  the  breaking 
up  of  their  organic  combinations,  but  nothing  definite  is  known  about  the 
import  of  these  changes  in  the  physiology  of  nutrition.  The  ferments  and 
the  most  of  the  immune  bodies  are  destroyed  at  60°-80°  C.  (140°-180°  F.). 

As  the  child  develops,  it  is  finally  able  to  utilize  the  mixed  diet  of  the 
adult,  the  discussion  of  which  is  not  essential  here. 

During  the  first  year  of  life,  the  child  takes  nourishment  entirely  by 
suckling  and  swallowing.  It  is  only  towards  the  end  of  the  second  year,  when 
the  premolars  have  developed,  that  the  child  learns  to  masticate  his  food. 


8  TEXT-BOOK  OF  PEDIATRICS 

In  suckling  from  the  mother's  breast,  even  the  new-born  may  develop 
considerable  negative  pressure.  But  this  negative  pressure  of  the  oral 
cavity  is  by  no  means  the  only  factor  in  the  extraction  of  the  milk.  Besides 
this  the  closure  of  the  jaws  and  the  pressure  upon  the  musculature  of  the 
areola  cause  a  reflex  relaxation  of  the  sphincter  muscles.  Psychic  influence 
also  plays  some  part  in  the  relaxation  of  the  breast.  From  the  very  com- 
plexity of  these  reflex  reactions,  we  may  anticipate  that  there  are  wide 
individual  differences  in  the  ease  with  which  the  breast  may  be  emptied, 
even  though  the  suckling  powers  of  the  children  be  equal.  This  proves 
especially  true  when  the  milk  is  expressed  or  pumped  out. 

The  liquid  nourishment  passes  the  comparatively  small  mouth  of  the 
infant  rapidly.  According  to  Tobler's  observations  on  a  four-year-old  boy, 
3-5  c.c.  of  saliva  are  added  to  100  c.c.  of  milk.  In  children  during  the  first 
four  months,  in  whom  the  mouth  is  comparatively  dry  and  the  secretion 
of  saliva  scant,  there  is  probably  even  less  admixture.  By  the  fourth  to  the 
sixth  month,  the  secretion  is  much  more  abundant  and  until  the  child 
learns  to  swallow  the  saliva  it  may  run  from  the  mouth. 

Attention  may  be  called  to  certain  anatomical  peculiarities  of  the 
infant's  mouth  which  fit  it  for  the  mechanics  of  suckling.  The  inner  mar- 
gin of  the  lips  is  studded  with  numerous  papilla?  (the  pars  villosa)  and  the 
middle  portion  of  the  upper  lip  is  prolonged  in  a  median  labial  tubercle. 
These  structures  with  a  series  of  marked  transverse  ridges  or  rugce  on  the 
hard  palate  aid  in  holding  the  nipple.  The  collapse  of  the  lateral  parts  of 
the  cheeks  in  the  suckling  act  is  prevented  by  the  presence  of  the  sucking 
pads,  specialized  masses  of  fat  which  lie  below  the  superficial  fascia  and 
are  pressed  against  the  gums  when  a  negative  pressure  is  produced  in  the 
oral  cavity.  Hasse  has  pointed  out  that  in  sucking,  the  milk  passes  the 
mouth  by  way  of  two  functional  passages — the  median  salivary  cavity, 
between  the  tongue  and  soft  palate,  and  the  lateral  salivary  cavity  between 
the  cheeks  and  gums.  In  either  case  the  .fluid  is  discharged  into  the  pharynx 
through  narrow  posterior  apertures  lying  between  the  soft  palate  and 
larynx  medially  and  the  posterior  pillars  of  the  fauces  laterally.  As  the 
larynx  lies  at  a  relatively  high  level  it  is  possible  for  fluids  to  pass  through 
these  openings  into  the  lower  part  of  the  pharynx  without  entering  the 
cavity  of  the  larynx  even  when  this  structure  is  open. 

Ptyalin  is  certainly  found  in  the  saliva  of  the  new-born,  although  in 
small  quantities,  but  there  is  nothing  in  the  milk  upon  which  it  can  act. 
When  gruels  or  flour  are  added  to  the  diet,  its  function  is  required. 

The  stomach  of  the  young  infant  is  but  slightly  developed  as  to  the  fun- 
dus;  the  lesser  curvature,  because  of  the  fulness  of  the  intestine,  is  more 
horizontal  and  its  concavity  is  directed  backward  instead  of  to  the  right,  as 
in  the  adult.  This  peculiarity  changes  as  soon  as  the  child  begins  to  stand 
and  to  walk,  when  the  vertical  position  of  the  organ  develops.  The  capacity 
of  the  stomach  is  at  first  very  small ;  varying  in  individuals  and  according 
to  diet;  it  increases  rapidly  in  size  as  the  child  grows  older.  Exact  figures 
can  hardly  be  given  because  the  capacity  and  the  distensibility  are  not 
identical  under  varying  conditions  of  feeding.  Such  conclusions  as  may  be 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES          9 

drawn  from  the  quantities  of  food  that  the  healthy  child  spontaneously 
takes  are  noted  in  the  second  chapter.  It  is  an  established  fact,  however, 
that  the  healthy  breast-fed  babe  occasionally  takes  much  greater  quantities 
of  food  at  one  time  than  would  seem  possible,  according  to  the  capacity  of 
the  stomach,  and  it  has  been  shown  that  part  of  the  milk  passes  unchanged 
from  the  stomach  into  the  intestine  while  the  child  is  nursing.2 

The  histologic  structure  of  the  stomach  wall  evidently  shows  no  great 
differences  from  that  of  the  adult.  The  hydrochloric  acid  and  all  the 
digestive  ferments  are  present  in  the  stomach  of  the  new-born. 

The  casein  formation  in  the  stomach  occurs  rapidly  with  cow's  milk, 
after  it  has  become  acid  in  reaction.  With  human  milk  the  process  is 
slower.  In  the  former  larger  flakes  of  curd  are  formed  than  in  the  latter. 
The  whey,  which  is  separated  after  coagulation  and  which  contains  the 
greater  part  of  the  salts,  the  milk-sugar,  the  so-called  soluble  milk  proteins, 
and  other  constituents  about  which  little  is  known,  is  soon  acted  upon  suffi- 
ciently by  the  pepsin  and  hydrochloric  acid  to  permit  its  passage,  in  frac- 
tional quantities,  into  the  intestine  for  its  further  digestion  by  trypsin  and 
erepsin.  The  casein  in  the  stomach  content,  which  gradually  becomes 
more  solid,  is  digested  more  slowly  but  in  an  analogous  manner,  the  fer- 
ments attacking  the  outer  surface  and  digesting  it.  If  more  cow's  milk  be 
put  into  the  stomach  before  this  dense  mass  of  cheese  is  completely  dis- 
solved, the  new  milk  spreads  itself  between  the  stomach  wall  and  the  outer 
surface  of  its  older  content  and  prevents  its  further  digestion  by  taking  up 
the  hydrochloric  acid  and  the  ferments.  It  is  possible  that  abnormal  changes 
in  the  direction  of  decomposition  may  develop  in  this  central  mass. 

The  presence  of  free  hydrochloric  acid  is  dependent  not  only  upon  the 
total  quantity  secreted,  but  also  and  directly  upon  the  power  of  the  food  to 
combine  with  it.  For  this  reason  it  is  present  in  the  stomach  of  the  breast- 
fed infant  after  one  to  one  and  a  half  hours,  and  in  the  child  fed  with  cow's 
milk  only  after  two  and  a  half  to  three  hours.  This  is  important,  because 
the  free  hydrochloric  acid  has  an  antiseptic  action  which  the  combined  acid 
does  not  possess. 

N 

The  total  acidity,  varying  from  20-60  c.c.  —  acidity  per  100  c.c.  of  con- 
tent is  due  to  the  organic  acids  and  acid  salts,  and  especially  the  acid  phos- 
phates present,  rather  than  to  the  hydrochloric  acid.  The  organic  acMs 
arise  partly  from  the  action  of  the  ferment  lipase  upon  the  fats,  which 
occurs  in  small  measure  in  the  stomach,  and  partly  from  bacterial  action. 

Flour  or  gruels,  given  with  or  without  additions  of  milk,  are  not  only 

2  The  stomach  of  the  new-born  infant  is  usually  almost  vertical  in  position  with  the 
greater  curvature  to  the  left.  The  transverse  type  of  stomach  characteristic  of  infancy 
is  established  with  the  distention  of  the  viscus  at  birth  either  with  injected  fluid  or  with 
air  and  mucus.  Until  this  distention  has  taken  place  the  anterior  surface  of  the  organ 
lies  entirely  under  the  cover  of  the  liver  and  is  usually  covered  in  part  by  the  gastric 
surface  of  the  spleen.  The  average  anatomic  capacity  of  the  stomach  is  about  1  ounce 
(33  c.c.)  at  birth.  This  is  doubled  in  the  first  ten  days,  tripled  in  the  first  month  and 
increased  over  6-fold  by  the  end  of  the  first  six  months.  After  the  first  four  or  five  days 
the  size  of  the  average  feeding  is  about  a  fifth  to  a  quarter  more  than  the  anatomic 
capacity  of  the  stomach  at  the  same  age. 


10  TEXT-BOOK  OF  PEDIATRICS 

changed  digestively  by  the  long  continued  action  of  the  p.tyalin  of  the  saliva, 
but  are  split  further  by  bacteria  mixed  with  them,  inducing  a  fermenta- 
tion, the  products  of  which  are  usually,  in  part,  low  fatty  acids. 

The  duration  of  gastric  digestion  in  the  healthy  child  depends  upon  the 
kind  and  quantity  of  the  food.  After  an  abundant  feeding  of  breast-milk, 
the  stomach  is  empty  at  the  end  of  two  hours,  and  after  the  same  quantity 
of  cow's  milk  it  is  emptied  in  three  hours.  Smaller  feedings  leave  the  stom- 
ach in  a  correspondingly  shorter  time.  These  digestive  periods  obtain 
only  in  healthy  children;  even  the  slightest  disturbance  may  influence  the 
motility  of  the  stomach  so  greatly  that  the  food  may  remain  for  an  hour  or 
so  longer. 

The  rapidity  with  which  the  stomach  empties  is  regulated  by  the  closure 
of  the  pylorus  which  is  stimulated  reflexly  by  the  content  both  of  the 
stomach  and  of  the  duodenum.  According  to  Tobler's  investigations,  food 
rich  in  fat  delays  its  emptying. 

Small  quantities  of  salt  and  sugar  solutions  and  of  albumoses  are 
absorbed  by  the  gastric  mucosa.  The  larger  part  of  the  food  mass  passes 
into  the  intestine. 

The  acidity  of  the  gastric  contents  is  reduced  in  the  duodenum  by  the 
addition  of  sodium  carbonate,  of  which  the  pancreatic  juice  contains  a 
large  percentage.  This  causes  a  withdrawal  of  alkali  from  the  body. 

The  digestive  changes  in  the  intestinal  tract  apparently  occur  in  the 
same  manner  as  in  the  adult.  All  the  ferments  of  the  intestine  and  the 
contiguous  glands,  even  including  the  prosecretin  and  the  hormone  se- 
cretin,  which  are  found  in  the  adult,  are  present  in  the  new-born,  and,  for  the 
most  part,  have  been  identified  in  the  fetus. 

A  more  detailed  description  of  the  digestive  function  is  hardly  neces- 
sary here;  but  a  few  special  points  may  be  emphasized.  As  we  have  said, 
the  absorption  of  the  so-called  soluble  milk  proteins  unchanged  was 
formerly  accepted  as  a  fact.  This,  however,  has  been  disproved.  They, 
as  well  as  the  casein,  are  split,  in  part  even  in  the  stomach,  to  the  finer 
divisions  of  the  protein  molecule  (amino-acids,  and  peptids)  and,  if  they 
are  not  oxidized,  are  used  in  the  intermediate  metabolism  of  the  synthesized 
body  protein.  This  is  true  even  of  the  proteins  of  the  human  milk. 

Milk-sugar  (lactose)  if  not  given  in  quantities  beyond  the  limits  of 
digestion  and  absorption,  is  split  by  the  ferment  lactase  into  dextrose  and 
galactose.  If  this  enzymic  action  is  not  complete  and  if  the  remaining 
portion  is  not  fermented  by  bacteria  in  the  intestine,  the  milk-sugar  may 
be  absorbed  unchanged  and  is  then  excreted  in  the  urine,  as  it  is  if  paren- 
terally  formed.  This  incident  plays  a  part  in  pathologic  conditions. 

For  the  clear  understanding  of  many  of  the  metabolic  processes  which 
are  to  be  described  later,  attention  must  be  called  to  the  fact  that  not  only 
are  the  products  of  the  digested  food  absorbed  during  the  whole  course  of 
gastro-intestinal  digestion,  but  that  there  is,  also,  a  secretion  of  a  very  con- 
siderable quantity  of  fluids  containing  proteins  and  salts  into  the  tract.  It 
should  be  noted,  further,  that  the  colon,  in  which  no  actual  digestion  occurs, 
is  an  organ  of  absorption,  as  well  as  of  excretion,  and  especially  for  the 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES  11 

earthy  and  fixed  alkalis  and  for  iron  and  phosphorus.  The  tune  necessary 
for  the  passage  of  food  through  the  intestine  varies,  normally,  from  twelve 
to  thirty-six  hours. 

The  feces,  consisting  of  particles  of  undigested  food  and  remnants  of 
the  secretions  of  the  intestinal  tract  and  of  the  glands  accessory  to  it, 
together  with  a  considerable  number  of  bacteria,  naturally  vary  in  consist- 
ency, color,  odor  and  mass  with  the  kind  and  quantity  of  food  ingested, 
with  the  intensity  of  the  various  secretory  influences,  and  with  the  rapidity 
of  the  peristalsis. 

The  first  evacuations  of  the  new-born  consist  partly  of  epithelial  debris 
and  of  the  secretions  of  the  fetal  intestinal  tract  and  its  adjacent  glands 
and,  in  part,  of  the  constituents  of  the  ingested  amnionic  fluid  and  of  sub- 
stances found  in  it,  e.  g.,  lanugo,  epidermal  cells,  etc.  Its  dark  green  color 
and  viscid  quality,  giving  to  it  the  name  of  meconium,  disappear  so  soon  as 
the  results  of  milk  digestion  appear  in  the  stool.  This  usually  occurs 
between  the  second  and  fifth  day. 

Under  normal  conditions  the  stool  of  the  breast-fed  infant  has  a  salve- 
like  consistency,  is  egg-yellow  in  color,  and  has  an  aromatic  and  acid  odor. 
The  bowel  movements  should  occur  once  or  twice  in  twenty-four  hours. 
More  frequent  bowel  movements,  generally  regarded  as  signs  of  chronic 
dyspepsia,  occur  with  surprising  readiness  in  children  who  are  developing 
normally.  They  are  thin  or  watery,  non-homogeneous  and  lumpy,  or  con- 
tain shreds,  and  are  full  of  minute  particles  of  greenish  mucoid  material  in 
which  traces  of  fecal  matter  are  imbedded.  The  odor  alone  is  like  that  of 
the  normal  breast-milk  stool;  it  may  be  of  stronger  quality,  but  it  never  has 
the  offensive  character  of  putrefactive  feces.  According  to  the  researches 
of  Gregor,  we  are  justified  in  the  belief  that  the  appearance  of  such  stools, 
which  are  usually  poor  in  substance,  is  due  to  a  relative  reduction  of  the 
amount  of  fat  in  the  breast-milk,  although  an  increased  irritability  of 
the  secretory  and  motor  functions  of  the  intestine  must  be  presumed  as  a 
causative  factor. 

Attention  must  be  called  to  the  fact  that  stools  which  are  yellow  when 
passed  may  change  to  a  green  color  when  left  exposed  to  the  air  for  a  time. 
While  the  conditions  necessary  for  the  oxidation  of  bilirubin  to  biliverdin, 
in  the  intestine  or  after  evacuation,  are  not  fully  understood,  it  must  be 
stated  emphatically  that  the  condition  is  not  in  itself  pathologic. 

In  artificial  feeding  with  dilutions  of  cow's  milk,  or  with  mixtures  of 
cow's  milk  and  gruels  or  flour,  the  stool  is  usually  better  formed,  is  lighter 
in  color  than  the  breast-milk  stool,  and  has  a  slightly  unpleasant  or  even  a 
putrefactive  odor.  Its  reaction  to  litmus  is  alkalin.  Every  deviation 
from  type  in  the  artificially-fed  must  be  taken  much  more  seriously  than 
variations  in  the  stools  of  the  breast-fed  infant  and  must  be  regarded  as  a 
possible  symptom  of  disturbance  of  nutrition. 

As  the  change  to  a  mixed  diet,  with  only  moderate  quantities  of  milk,  is 
made,  the  normal  bowel  movements  take  on  the  characteristic  consistency 
of  the  evacuations  of  the  adult. 

The  entire  digestive  tract,  from  mouth  to  anus,  offers  a  suitable  soil  for 


12  TEXT-BOOK  OF  PEDIATRICS 

the  growth  of  numerous  varieties  and  strains  of  bacterial  flora.  It  may  be 
readily  understood  that,  even  during  the  first  few  hours  after  birth,  the 
gastro-intestinal  tract  becomes  infected,  both  by  way  of  the  mouth  and 
the  anus,  with  numerous  micro-organisms  from  its  immediate  surroundings. 
All  do  not  enter  in  the  same  manner,  nor  do  all  find  an  equally  fertile  soil. 
It  is  manifestly  true  that  the  bacteria  found  in  the  stool  of  the  breast-fed 
child  are  of  other  varieties  and  of  lesser  number  than  those  seen  in  the  stool 
of  the  artificially-fed  infant. 

In  the  bowel  of  the  breast-fed  infant,  the  number  of  the  anaerobic 
bacillus,  bifidus  communis  (Tissier)  greatly  exceeds  that  of  the  aerobic 
bacilli,  coli  communis  and  the  bacillus  lactis  aerogenes  (Escherich). 
Besides  these,  streptococci,  the  bacillus  acidophilus,  the  bacillus  butyricus 
immobilis  (the  bacillus  perfringens  of  the  French  authors),  the  "Koepfchen 
bacteria,"  (Escherich)  the  anaerobic  bacillus,  butyricus  mobilis,  and  the 
bacillus  putrificans  coli  (Bienstock)  which  causes  putrefaction,  and  several 
others,  are  commonly  found.  In  the  artificially-fed  infant,  the  colon 
bacillus  and  the  intestinal  cocci  are  most  common,  but  many  of  those  named 
above  are  also  present  and  usually  in  larger  number  than  in  the  stool  of  the 
breast-fed  child. 

From  the  clinical  point  of  view,  and  for  several  reasons,  the  intestinal 
bacteria  are  interesting.  From  experimental  researches  upon  new-born 
animals,  which  die  when  a  sterile  gastro-intestinal  tract  is  maintained,3  it 
seems  possible  that  an  irreplaceable  physiologic  function  is  performed  by 
them  in  the  human  infant.  The  fact  that  a  continual  germicidal  activity 
is  exhibited  throughout  the  small  intestine,  especially  in  the  intervals 
between  the  digestive  acts,  and  that  rapid  bacterial  growth  occurs  only 
in  the  colon,  where  the  actual  digestive  process  is  completed,  makes  the 
problem  a  difficult  one  to  solve.  Nevertheless,  the  influence  of  the  intesti- 
nal flora  upon  the  reactions  of  the  intestinal  content  has  been  established. 
These  producers  of  fermentation  and  putrefaction  exist  in  constant  antag- 
onism to  each  other  and  determine  an  acid  or  alkalin  reaction  of  the  feces, 
according  to  the  predominance  of  each  type.  Of  course,  the  kind  of  food, 
apart  from  the  general  condition  of  the  organism,  has  an  influence  in  deter- 
mining this  predominance. 

Finally — another  point  not  to  be  overlooked — is  the  possibility  that 
under  certain  circumstances,  with  an  increase  of  the  usually  harmless 
saprophitic  bacteria,  they  may  acquire  a  virulence  which  makes  them 
pathogenic  to  the  particular  infant. 

While  the  kidneys,  relatively  large  in  the  new-born  and  during  infancy, 
show  normally  some  degree  of  fetal  lobulation,  they  generally  resemble 
those  of  the  adult;  so,  also,  does  the  urinary  tract.  The  urine,  during  the 
first  few  days  of  life,  is  scanty  and  concentrated,  tallying  with  the  small 
quantity  of  fluid  ingested  and  the  large  water  output  from  the  lungs.  It 
contains  a  relatively  large  quantity  of  uric  acid  in  an  amorphous  or  crys- 
talline form.  The  explanation  of  the  cause  of  albuminuria  in  the  new-born, 

3  Schottelius  vs.  Thierfelder,  Nuttel,  etc. 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES          13 

the  subject  of  much  discussion,  an  event  common  only  during  the  first  and 
second  weeks  of  life  and  but  rarely  of  longer  duration,  is  no  more  definite 
than  that  of  the  occurrence  of  uric  acid  infarcts.  Without  going  deeper  into 
these  questions,  amply  and  critically  discussed  by  Czerny  and  Keller,  it 
may  be  asserted  with  confidence  that  this  albuminuria  and  these  infarcts, 
while  probably  non-physiologic,  are,  at  most,  conditions  not  particularly 
harmful  to  the  individual. 

The  kidneys  weigh  about  25  grams  in  the  new-born  and  increase  in 
weight  between  19-  and  14-fold  between  birth  and  maturity.  They  double 
their  weight  in  the  first  year  and  triple  it  by  three  years.  They  form  about 
€.6  per  cent,  of  the  body-weight  in  the  new-born  as  compared  with  0.2  to  0.3 
per  cent,  in  the  adult.  They  occupy  a  relatively  larger  proportion  of  the 
posterior  abdominal  wall  in  infancy  than  in  later  life,  their  lower  poles 
generally  lying  below  the  iliac  crests  and  their  upper  poles  extending  to  the 
eleventh  or  even  the  tenth  ribs.  Their  adult  skeletal  relations  are  estab- 
lished as  the  child  habitually  assumes  the  erect  posture  and  the  lumbar 
region  elongates. 

The  bladder  is  almost  entirely  an  abdominal  structure  at  birth  and  in 
early  infancy.  In  the  contracted  state  its  apex  lies  about  midway  between 
the  umbilicus  and  pubis  on  the  anterior  abdominal  wall  and  its  base  lies 
behind  the  middle  third  of  the  symphysis  pubis.  When  filled  the  fundus 
may  lie  above  the  level  of  the  umbilicus 

So  soon  as  the  course  of  nutrition  is  normally  established  a  close  relation 
between  the  quantity  of  water  taken  and  the  quantity  of  urine  excreted 
becomes  clear;  from  60  to  70  per  cent,  of  the  ingested  water  reappearing 
in  the  urine.  Of  course  this  is  true  only  under  perfectly  normal  conditions. 
The  urine  is  voided  about  three  times  as  frequently  as  food  is  taken  and,  if 
water  be  given  between  meals,  micturition  may  occur  twenty  or  twenty-five 
times  in  the  twenty-four  hours.  We  are  not  justified  in  speaking  of  phys- 
iologic incontinence  in  the  infant;  for  there  is  no  continuous  flow  of  urine. 

The  infantile  penis  varies  greatly  in  size  in  different  individuals.  Nor- 
mally there  is  more  or  less  complete  phimosis  and  usually  but  a  pinhead 
opening,  with  complete  adhesion  between  the  glans  and  the  inner  surface  of 
the  prepuce.  Neither  this,  nor  the  presence  of  epithelial  concretions  in  the 
region  of  the  coronary  sulcus,  should  be,  under  any  circumstances,  an 
excuse  for  superfluous  and  disfiguring  operations  for  phimosis.  At  the 
present  time  it  is  necessary  to  lay  special  stress  upon  this  point. 

The  vulva  of  the  female  infant  gapes  because  of  the  slight  development 
of  the  labise.  This  physiologic  prolapse  is  favorable  to  the  entrance  of 
fecal  particles  into  the  urethra  and  the  resulting  occurrence  of  cystitis. 
This  etiology  of  cystitis  is  more  fully  discussed  in  the  chapter  on 
Genito-urinary  Diseases. 

The  skin  of  the  infant,  because  of  the  thinness  of  the  epithelial  layer  and 
the  greater  vascularity  of  the  papillary  layer,  is  more  tender,  softer  and 
more  intensely  colored  than  in  later  years.  These  differences  are  most 
marked  in  the  new-born,  whose  skin  is  so  vascular  during  the  first  few  days 
that  a  physiologic  erythema  neonatorum  is  described.  In  all  diseased  con- 


14  TEXT-BOOK  OF  PEDIATRICS 

ditions  and,  especially  in  disturbances  of  nutrition,  a  distinct  pallor  rapidly 
takes  the  place  of  the  blush  of  health,  or,  a  more  serious  symptom,  a  slate- 
gray  coloring  may  appear. 

The  subcutaneous  fat  is  present  and,  in  normal  conditions,  fairly  well 
developed  over  the  whole  body  and  even  over  the  extensor  surfaces  of  the 
joints  where  it  is  absent  later  in  life.  When  the  watery  and  saline  constit- 
uents of  the  organism  are  normal,  the  fat  gives  to  the  skin  of  the  infant  a 
tensity  and  elasticity — "turgor" — which,  with  its  fresh  color,  is  a  distinct 
indication  of  health. 

The  anatomic  development  of  the  sweat  glands  is  slight,  while  the 
opposite  is  true  of  the  sebaceous  glands  which  are  well  formed.  The  func- 
tional scantiness  of  the  perspiration  and  the  abundance  of  the  secretion  of 
sebum  in  the  new-born  tally  with  these  facts. 

Finally,  the  mammary  glands,  which  are  modified  cutaneous  organs, 
should  be  mentioned.  In  both  sexes  the  body  of  the  gland  represents  a 
flat  disc,  not  more  than  one  centimeter  in  thickness.  It  is  usually  sur- 
mounted by  a  pale,  indistinct  areola,  in  the  centre  of  which  is  the  mammilla 
about  the  size  of  a  pinhead.  An  increase  in  the  volume  and  an  active 
functioning  of  the  gland  during  the  third  or  fourth  day  of  life  is  quite  a 
common  rule.  This  is  probably  due  to  the  action  of  the  same  hormone, 
circulating  in  the  blood  of  the  babe,  which  stimulates  lactation  in  the 
mother.  Since  the  secretion  ("witch's  milk")  is  not  normally  excreted 
and  congestion  results,  the  fluid  has  the  consistency  of  colostrum.  During 
the  first  few  days  of  the  first  month,  the  secretion  completely  disappears. 
Histologic  evidences  of  milk  secretion,  in  the  form  of  dilated  ducts  and 
alveoli  containing  remains  of  secretion,  may  be  found  six  months  or  more 
after  birth. 

The  body  temperature4  of  the  infant  depends  upon  the  temperature 
of  its  surroundings  to  a  greater  extent  than  that  of  the  adult.  This  is 
especially  noticeable  in  premature  infants  and  in  those  who  are  congeni- 
tally  weak,  so  that  we  may  speak  of  a  poikilothermia  in  these  cases.  This 
condition  may  also  appear,  however,  in  normally  strong  children.  Its  cause 
is  in  part  found  in  the  thinner  epithelial  layers  and  the  greater  vascularity 
of  the  skin.  On  the  other  hand,  the  low  water  output  from  the  skin  of  the 
new-born  and  the  relative  excess  of  the  body  surface  to  its  actual  volume.5 
are  material  factors.  Slight  irregularities  in  heat  distribution,  which  is 
largely  a  function  of  the  body  surface,  may  cause,  therefore,  slight  variations 
of  body  temperature  the  more  readily  because  the  relatively  small  body 
mass  is  less  able  to  equalize  them  by  rapid  changes  in  heat  production. 

It  is  not  necessary  to  discuss,  in  this  connection,  the  inadequacy  of 
thermal  regulation  due  to  the  non-development  of  thermotaxic  and  thermo- 
inhibitory  centres,  since  analogies  in  other  nerve  functions,  as  in  the  motor 
field  of  the  new-born,  justify  the  assumption.  However  this  may  be,  clinical 

4  See  technic  of  examination. 

5  In  the  new-born  we  have,  for  each  kilo  of  body- weight,  approximately  810  square 
centimeters  of  surface;  at  six  months,  620  square  centimeters;  at  twelve  months,  530 
square  centimeters;  at  four  years,  we  still  have  500  square  centimeters;  while  the  adult 
has  only  300  square  centimeters. 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES          15 

observation  has  proved  that  young  infants  may  be  cooled  or  overheated  by 
external  influences  much  more  readily  than  older  children.  There  is,  at 
least,  a  reduced  range  of  physiologic  heat  regulation.  Within  these  limits, 
it  is  nevertheless  very  exact.  The  healthy  infant,  surrounded  by  non-con- 
ducting substances,  maintains  a  temperature  between  36.8°  and  37.2°  C. 
(98.2°-99°  F.)  almost  continuously  without  the  aid  of  external  heat. 
These  figures  mark  the  slight  morning  and  evening  range  of  temperature  by 
rectum.  This  practical  monothermia,  according  to  the  careful  studies  of 
Jundell  and  Goffer je,  who  took  temperatures  every  two  to  four  hours  by 
rectum,  is  found  only  during  the  first  few  weeks  of  life.  By  the  second 
month,  the  temperatures  similarly  taken,  revealed  variations  up  to  1°  C. 
(1.8°  F.)  a  range  in  which,  under  regular  conditions  of  sleep  and  growth, 
may  be  recognized  a  nightly  fall  and  a  daily  plateau.  Irregular  variations 
and  increases  over  37.5°  C.  (100°  F.)  in  children  who  have  not  been 
artificially  warmed  by  hot-water  bottles  or  similar  agencies,  must  be 
considered  pathologic. 

THE  PHYSIOLOGY  OF  METABOLISM 

Attention  has  already  been  called  to  the  great  importance  of  the  role 
which  the  nutrition  and  allied  phenomena  assume  in  the  life  of  the  infant — 
an  importance  which  will  be  emphasized  in  other  portions  of  the  work. 
It  seems  necessary,  therefore,  to  devote  a  special  chapter,  in  addition 
to  the  subsequent  detail  of  the  process  of  digestion,  to  the  physiology 
of  metabolism. 

a.  NITROGEN 

Nitrogen  is  present  in  milk  almost  entirely  in  the  form  of  protein.  The 
researches  of  Bahrdt  and  Langstein  upon  new-born  animals  have  demon- 
strated that  even  the  protein  materials  of  the  milk  of  the  mother  animal 
undergo  very  complete  metabolism  into  amino  acid  and  amino  acid  com- 
plexes (peptids).  There  is  no  reason  why  the  results  of  these  researches 
may  not  be  transferred  to  the  human  new-born.  If  this  were  done,  the 
hypotheses  based  upon  the  differing  effects  of  feeding  homologous  and 
heterologous  proteins,  as  represented  in  natural  and  artificial  feeding 
would  lose  support,  unless  we  also  assume  that  their  comparatively  simple 
cleavage  products  (amino-acids,  etc.),  retain  the  identical  characteristics 
of  the  protein  from  which  they  are  derived.  In  support  of  this  latter  posi- 
tion, however,  no  definite  proof  has  as  yet  been  advanced.  Recently  various 
researches  tend  to  show  that  foreign  protein  (egg)  may  be  absorbed  un- 
changed in  certain  nutritional  disturbances.  These  proteins  may  be 
found  in  the  blood  and  urine;  the  quantities  depend  upon  the  severity  of 
the  disturbance. 

The  nitrogen  requirement  of  the  infant  is  evidently  small,  as  indicated 
by  the  low  nitrogen  content  of  human  milk.  This  should  be  remembered 
in  studying  the  requirements  of  the  nutrition  and  the  period  of  the  greatest 
relative  growth,  for  it  shows  how  little  an  excessive  protein  diet  can  be 
justified  by  the  indications  of  the  demands  of  natural  growth.  Certain 


16  TEXT-BOOK  OF  PEDIATRICS 

authors  claim  that  the  protein  need  of  the  growing  infant  is  fully  supplied 
when  7  per  cent,  of  its  caloric  need  is  supplied  in  protein.  The  first  few  days 
of  life  only,  the  period  of  the  so-called  physiologic  loss  of  weight,  present  an 
exception  to  this,  for  if  the  child  be  nourished  during  this  period  with  milk 
of  an  established  lactation  there  is  a  distinct  loss  of  body  nitrogen,  which  is 
avoided  if  colostrum,  which  contains  much  more  nitrogen  than  does  the 
fuU  milk  (Birk)  be  fed. 

In  the  healthy  child  the  absorption  and  retention  of  nitrogen  is  very 
complete.  The  dried  feces  contain  only  4-4^2  per  cent,  of  nitrogen,  and  even 
this  small  amount  consists  only  in  part  of  the  nitrogen  of  the  food  which 
has  escaped  absorption.  At  least  an  equal  share  comes  from  the  nitrogen 
containing  secretions  of  the  intestine  and  its  auxiliary  glands  and  from  the 
bacteria  present.  The  retention  is  represented  by  the  difference  between 
the  intake  and  the  excretion  in  the  feces  and  urine,  but  it  may  be  said  that 
a  positive  N.  balance  is  not  necessarily  indicative  of  growth  or,  rather,  of 
tissue  building.  Nitrogen  retention  may  occur  temporarily  during  periods 
of  weight  loss. 

The  end  products  of  nitrogen  metabolism  in  the  urine  are  the  same  as  in 
the  adult,  excepting  that  the  amount  of  ammonia  is  normally  somewhat 
greater.  This  will  be  more  fully  discussed  in  the  chapter  on  Disturbances 
of  Nutrition. 

As  in  the  adult,  the  addition  of  carbohydrate  to  the  protein  food  leads 
to  an  increased  N.  retention,  in  spite  of  a  poorer  N.  resorption,  while  fat 
reduces  the  N.  absorption  as  well  as  the  N.  retention  very  slightly.  This, 
however,  is  of  no  practical  importance  under  normal  conditions,  since  the 
nitrogen  intake  always  exceeds  the  minimal  requirements.  It  may  become 
important  in  pathologic  conditions. 

6.  FAT 

The  fat  taken  in  milk  feeding  consists  of  neutral  fats  and  contains  only 
small  amounts  of  free  fatty  acids. 

As  already  stated,  a  slight  fat-splitting  by  lipase  occurs  in  the  stomach 
of  the  infant.  It  is  probably  much  less  than  takes  place  in  the  stomach  of 
the  adult,  where  the  strong  lipolytic  secretions  of  the  small  intestine  nor- 
mally flow  back  into  the  stomach  and  initiate  a  more  complete  breaking  up 
of  the  fats.  The  purpose  of  this  is  probably  to  facilitate  the  emulsification 
of  the  coarser  fat  droplets  by  the  alkalin  carbonate  of  the  pancreatic  juice, 
which  is  dependent  upon  the  presence  of  free  fatty  acids.  In  the  infant 
whose  fatty  food  is  taken  in  the  form  of  a  fine  emulsion  this  is  unnecessary. 

The  amount  of  fat  taken  with  the  food  varies  greatly  in  the  breast-fed 
child,  not  only  from  day  to  day,  but  also  in  the  several  feedings;  doubling 
in  quantity,  in  some  instances,  with  the  increase  of  the  volume  and  the  fat 
content  of  the  different  meals.  This  is  readily  understood  when  we  recall 
the  variations  of  the  fat  content  of  the  human  milk  stated  above.  In  the 
artificially-fed  child  these  variations  do  not  usually  occur,  since  in  children 
fed  with  milk  mixtures,  of  closely  similar  quality  at  each  feeding,  the  total 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES          17 

amount  of  fat  ingested,  e\en  when  cream  is  added,  is  far  less  than  the 
breast-fed  babe  receives. 

More  than  nine-tenths  of  the  fat  ingested  is  absorbed  from  the  intestine 
of  the  healthy  infant.  Part  of  the  fat  recovered  from  the  feces  probably 
comes  from  the  intestinal  secretions  and  a  small  portion  of  the  volatile 
fatty  acids  may  originate  from  the  breaking  down  of  the  carbohydrates. 
The  fat  of  the  feces  consists  of  neutral  fats,  free  fatty  acids,  and  the  earthy 
alkalin  and  fixed  alkalin  salts  of  the  fatty  acids  (soaps).  It  is  found  in 
varying  quantity.  This  is  shown,  without  further  examination,  by  the  con- 
sistency, the  reaction  and  the  odor  of  the  evacuations,  in  so  far  as  the  fatty 
acids  are  in  excess  in  the  acid  stools;  while  in  the  dry  alkalin  feces  the 
earthy  alkalin  soaps  are  in  excess,  only  a  minor  part  (about  10  per  cent.) 
consisting  of  neutral  fat  which  shows  very  slight  variation. 

The  role  of  soap  formation  in  the  metabolism  of  the  fixed  and  alkalin 
earths  is  evidently  a  very  complicated  one  and,  up  to  the  present  time,  is  not 
fully  understood.  As  these  are  of  special  importance  in  pathologic  con- 
ditions we  dispense  with  their  full  discussion  here. 

The  absorbed  fat  is  required  by  the  body  partly  for  combustion  and  in 
part  as  a  reserve  of  storage  food. 

c.  CARBOHYDRATE 

Only  one  carbohydrate,  milk-sugar  (lactose)  is  contained  in  human  milk 
and  in  the  milk  of  animals.  It  is  a  disaccharide  and  splits  into  one  mole- 
cule of  glucose  (dextrose,  grape  sugar)  and  one  molecule  of  galactose.  These 
two  monosaccharides  are  combined  with  a  loss  of  one  molecule  of  water. 

Other  disaccharides  used  in  the  artificial  feeding  of  healthy  infants  are 
cane-sugar  (saccharose  =  dextrose  +  levulose  or  fructose) ;  and  maltose 
(  =  dextrose + dextrose)  the  latter  being  either  an  important  constituent  of 
the  commercial  malt  extracts,  or  a  product  of  enzymic  action  upon  starch. 

Preformed  monosaftcharides  are  not  contained  in  the  nutriment  of  the 
infant.  Only  when  the  child  is  able  to  take  honey  and  fruit  does  it  receive 
levulose  and  glucose,  as  such. 

Among  the  polysaccharides,  starch  and  cellulose  must  be  considered. 
The  former  is  a  constituent  of  the  pure  flours,  partially  dextrinized  in 
toast  (Zwieback)  and  found  in  several  of  the  so-called  infant  foods;  and  the 
latter  is  a  constituent  of  vegetables  and  fruits. 

It  is  generally  understood  that  only  the  monosaccharides  are  directly 
absorbed;  other  varieties  of  sugar  being  absorbed  only  after  they  have  been 
split  by  the  action  of  enzymes  and,  probably,  by  bacterial  action  as  well. 
Only  if  greater  quantities  are  ingested  than  can  be  broken  up  by  the 
enzymes  or  fermented  by  bacteria,  does  the  direct  absorption  of  disaccharides 
occur;  and  then  they  are  excreted  unchanged  in  the  urine,  even  as  they  are 
after  parenteral  absorption.  It  may  be  said,  in  this  event,  that  the  limit  of 
assimilation  has  been  exceeded.  The  polysaccharides  undergo  a  compli- 
cated splitting  before  absorption. 

It  has  been  stated  already  that  the  various  ferments  necessary  to  carbo- 
hydrate digestion  are  found  in  the  new-born,  even  though  in  very  small 
2 


18  TEXT-BOOK  OF  PEDIATRICS 

quantities.  This  is  true  both  of  the  diastase  of  the  saliva  and  the  amylo- 
lytic  secretion  of  the  pancreas.  In  view  of  their  scanty  presence,  it  is  prob- 
ably true  that  a  relatively  large  part  of  the  carbohydrate,  the  exact 
quantity  not  being  determined,  is  split  by  bacterial  action  (fermentation) 
with  the  formation  of  the  acid  products  of  this  decomposition. 

The  limit  of  assimilation  for  milk-sugar  and  maltose  is  higher  in  the 
infant  than  in  the  adult. 

The  carbohydrates  of  the  food  serve  in  the  infant,  even  as  in  the  adult, 
not  only  as  material  for  combustion  and  as  a  source  of  energy,  but  they 
facilitate  or  even  actualize  the  normal  potential  combustion  of  the  fats.  If 
they  are  absent,  a  disturbance  of  fat  metabolism  results,  recognized  by  the 
appearance  of  acetone  bodies  in  the  urine.  This  is  more  readily  developed 
in  the  infant  than  in  the  adult.  It  has  been  determined  that  a  moderate 
amount  of  lactose  in  the  diet  increases  the  nitrogen  retention,  but  that  large 
amounts  cause  a  negative  N.  balance.  Also  the  complete  withdrawal  of 
carbohydrates  causes  a  negative  N.  balance. 

The  amounts  of  blood  sugar,  as  recently  determined  by  Goetzky  using 
the  method  of  Bang,  are  0.085  per  cent,  average  for  infants  of  twelve  days; 
0.095  per  cent,  for  one  month;  and  0.102  per  cent,  at  one  year.  In  older 
children  other  authors  have  obtained  an  average  of  0.072  to  0.113  per  cent, 
which  are  approximately  the  same  as  the  variations  in  the  adult. 

d.  MINERAL  CONSTITUENTS 

Human  milk  contains  all  the  minerals  necessary  for  the  life  and  growth 
of  the  infant.  In  the  milk  of  the  domestic  animals  they  are  present  in  much 
larger  quantity,  corresponding  to  the  more  rapid  growth  of  their  young. 
So  plentiful  are  they,  in  fact,  that  in  the  feeding  of  the  healthy  infant  with 
the  usual  milk  dilutions  their  quantity  is  ample,  with  the  probable  excep- 
tion of  iron  which  is  very  scanty  in  both  human  and  animal  milk. 

The  close  relationship  of  inorganic  to  organic  metabolism,  and  the  rel- 
ative independence  of  individual  kations  and  anions  in  their  migration 
through  the  organism,  make  it  plain  that  one  mineral  substance  can  act 
vicariously  for  another  in  only  limited  measure.  In  fact,  the  continued 
absence  of  even  one  certain  ion  is  incompatible  with  growth  and  life.  The 
danger  of  its  lack  may  be  overcome  for  a  time  by  the  ability  of  the  tissues 
when  subjected  to  "salt  hunger"  to  retain  their  mineral  substances  with 
great  tenacity;  but  this  temporary  protection  is  broken  down  after  awhile. 
These  inorganic  ingredients  have  a  great  influence,  also,  upon  the  water 
content  of  the  organism. 

e.  WATER 

Water  plays  an  important  part  in  the  life  of  the  infant  because  the  child 
takes  more  than  double  the  quantity  of  water  with  his  food  per  kilo  of  body- 
weight,  than  does  the  adult.  His  body,  in  fact,  contains  relatively  more 
fluid.  As  with  other  tissue  components,  the  organism  regulates  this  water 
content,  not  according  to  the  quantity  obtainable,  but  according  to  its 
necessities,  By  the  figures  of  Camerer  it  is  shown  that  in  the  healthy 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES          19 

breast-fed  child  about  two-thirds  of  the  water  ingested  is  excreted  in  the 
urine,  and  only  1  to  2  per  cent,  remains  in  the  body;  the  remainder  leaving 
the  body  by  way  of  the  lungs,  the  skin  and  the  intestines. 

The  ingestion  of  larger  quantities  of  water  does  not  increase  the  storage 
but  the  excretion,  especially  by  the  kidneys;  and  since  always  it  takes  with 
it  soluble  substances  (urea,  salts,  etc.)  this  probably  leads  to  a  partial 
leaching  of  the  tissues.  In  order  to  increase  the  water  content  of  the  body, 
we  must  give  salts  or  other  substances,  e.  g.,  carbohydrates,  favorable  to 
water  retention,  in  addition  to  sufficiently  large  quantities  of  water.  On 
the  contrary,  a  reduction  of  the  water  retention  can  be  accomplished  only 
by  restricting  the  intake  of  salts  or  carbohydrates,  or  by  a  pathologic 
increase  of  the  secretion  of  water  and  salts.  The  simple  reduction  of  the 
water  intake  has  the  ordinary  result  of  reducing  its  excretion.  These  con- 
ditions probably  play  some  part  in  the  etiology  and  pathogenesis  of  the 
various  disturbances  of  nutrition.  It  seems,  at  times,  that  the  possibility 
of  regulating  the  water  balance  in  the  infant  is  less  developed  than  in  later 
life.  Perhaps  on  the  other  hand  the  amount  of  water  excreted  from  the 
body  by  the  way  of  the  intestine  and  the  power  of  water  retention  play  a 
most  important  role. 

/.  ACCESSORY  FOOD  SUBSTANCES 

It  has  recently  been  recognized  by  experiments  on  animals  and  by 
observation  on  the  human  that  there  must  be  other  food  elements  which  by 
their  presence  in  the  diet  promote  normal  growth  in  the  young  and  prevent 
so-called  "  deficiency  diseases"  in  the  adult.  To  these  Funk  has  applied  the 
name  of  "vitamins,"  but  Hofmeister's  term  of  "accessory  food  substances" 
seems  preferable  because  it  is  more  noncommittal.  Their  chemical  and 
biological  study  still  offers  a  large  field  for  research,  but  it  is  generally  recog- 
nized that  they  occur  in  small  quantities  in  certain  food,  and  that  they  are 
not  of  animal  origin,  but  are  transmitted  through  milk  and  meat  from  vege- 
table food.  Their  importance  as  an  etiologic  factor  of  beriberi  and  the 
analogous  polyneuritis  of  chickens,  of  scurvy,  and  of  keratomalacia  has 
been  proved.  In  rickets,  however,  it  is  apparently  only  a  factor.  The  anti- 
neuritic  principle  is  contained  in  most  vegetable  foods  and  the  form  of 
polyneuritis  known  as  beriberi  is  produced  only  by  a  continued  one-sided 
diet  with  polished  rice.  The  antiscorbutic  principle  is  found  in  fresh  green 
vegetables  and  certain  fruits  (lemons,  oranges,  raspberries  and  tomatoes), 
and  in  small  amounts  in  milk  and  meat.  It  is  quite  resistant  to  heat, 
drying  and  preserving.  The  antirickitic  element  is  found  in  green  leaf  vege- 
tables and  in  animal  oils  (butter,  cod-liver  oil,  yolk  of  egg).  Friese  was  able 
to  cure  the  keratitis  produced  by  the  specific  Hopkins  diet  by  adding  a  small 
amount  of  fresh  milk.  The  solution  of  the  innumerable  problems  arising 
from  the  study  of  the  accessory  food  substances  is  of  great  importance  to 
the  podiatrist. 

g.  THE  TOTAL  METABOLISM 

The  total  metabolism  of  the  child  demands  a  greater  intake  of  food  than 
in  the  adult  because  of  the  added  requirements  of  normal  growth.  If  the 


20  TEXT-BOOK  OF  PEDIATRICS 

larger  output,  through  the  several  channels  does  not  counteract  this  intake, 
the  margin  of  increase  will  be  very  slight,  since  even  in  the  period  of  most 
rapid  growth  the  greater  part  of  the  gain  in  weight  consists  of  water. 

Thus  Camerer  estimates  that  in  a  child  ten  weeks  old,  weighing  five 
kilos,  taking  800  gms.  of  breast-milk  per  day,  and  showing  an  average 
daily  gain  of  25  gms.,  the  increase  consists  of  18  gms.  of  water,  0.7  gms. 
mineral  substance,  3.0  gms.  of  protein  and  3.3  gms.  of  fat. 

Actually,  a  greater  intake  is  counterbalanced  by  a  notably  increased 
physiologic  output.  In  the  resting  infant,  this  output  is  the  larger  on 
account  of  its  relatively  greater  heat  radiation.  Attention  has  been  called 
to  the  fact  that  the  body  surface  of  the  infant,  as  compared  to  his  weight  or 
mass,  is  two  or  three  times  greater  than  that  of  the  adult.  And  since  the 
heat  radiation  runs  parallel,  in  definite  degree,  to  the  surface  area,  the  out- 
put of  the  metabolism  of  the  infant  would  be  two  to  three  times  as  great 
as  in  the  adult  and  the  intake,  in  order  to  maintain  a  positive  balance, 
would  have  to  be  that  much  greater.  As  an  actual  fact  Rubner  has  deter- 
mined experimentally,  in  his  researches  upon  adult  dogs  of  various  sizes, 
that  their  carbon  dioxide  excretion  is  proportionate  to  their  body  surface, 
other  things  being  equal ;  and  that  it  does  not  rise  or  fall  in  proportion  to 
their  body-weight.  Since  the  carbon  dioxide  excretion  may  serve  as  a 
measure  of  the  combustion  of  organic  substances,  in  accordance  with 
demonstrated  physiologic  principles,  a  close  relationship  is  thus  established 
between  surface  area  and  food  requirement.  This  food  requirement  may 
now  be  measured  by  its  caloric  value,  and  the  experimentally  established 
values  of  the  different  food  substances  may  be  rated  as  follows:  for  1  gm.  of 
protein  4.1  calories; 6  for  1  gm.  of  fat  9.3  calories;  and  for  one  gm.  of  sugar 
4.1  calories.  The  salts  do  not  present  a  calculable  caloric  value. 

Putting  the  clinical  conception  of  food  requirement  aside,  in  favor  of  the 
energy  requirement  or  rather  the  caloric  index,  which  lends  itself  readily  to 
physical  and  chemical  investigation,  the  latter  has  gained  recognition  in 
scientific  pediatrics  by  the  epoch-making  work  and  studies  of  the  elder 
Camerer,  of  Rubner  and  Heubner;  and  is  both  lauded  as  an  important 
advance  and  condemned  as  unscientific  and  contrary  to  clinical  experi- 
ence. It  may  be  acknowledged  at  once,  that  in  considering  food  as  an 
entity,  basing  its  value  upon  its  heat-producing  power,  we  must  accept 
as  a  premise  that  its  component  substances  are  capable  of  far-reaching 
physiologic  interchange.  This  is  based  upon  the  idea  of  isodynamia, 
that  is,  that  a  calorie  of  one  food  component  can  be  freely  substituted 
for  a  calorie  of  another  food  component  in  the  metabolism.  At  the  same 
time,  we  must  acknowledge  that  this  premise  is  true  only  to  a  limited 
degree  in  the  healthy  infant,  and  is  entirely  untrue  when  applied  to  the 
child  with  disturbances  of  nutrition.  Heubner,  to  whom  the  study  of  the 
problem  of  energy  requirement  in  infant  feeding  owes  its  greatest  advance, 
has  replied  to  objections  raised  by  Czerny  and  Keller,  when  they  feared 

6  Protein  gives  5.6  calories  in  the  calorimeter,  but  of  this  only  4.1  calories  are  physi- 
ologically available  as  useful  calories  in  the  organism,  while  1.5  calories  are  lost  in  nitro- 
genous excretions  (urea,  etc.)- 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES          21 

that  the  physical  viewpoint  in  the  teaching  of  infant  feeding  would  wholly 
supersede  the  physiologic-chemical  view,  by  emphasizing  that  this  is  not 
the  purpose  of  the  proponents  of  the  method,  but  that  the  aim  is  to  give  a 
better  quantitative  standard  of  the  food  requirement  of  the  infant  than 
was  given  by  any  former  methods  in  determining  the  volume  or  weight  of 
the  food.  He  further  asserts  that  with  this  common  standard  it  is  possible 
to  obtain  the  most  favorable  quantitative  variations  in  which  the  different 
food  substances  may  and  must  be  put  together.  The  energy  quotient  fur- 
nishes us  with  a  unifying  principle  and,  whatever  the  choice  or  qualitative 
composition  of  the  infant's  food,  informs  us  of  the  essential  quantities, 
which,  under  all  the  variances  in  age  and  condition  the  infant  demands. 

Apart  from  the  minor  fact  of  the  broad  interchangeability  of  various 
food  substances  in  infant  feeding,  the  adoption  by  the  clinic  of  the  caloric 
method  of  treating  the  feeding  problem  meets  with  two  other  sources  of 
error,  which,  while  reflecting  upon  its  absolute  exactness,  do  not  impair  its 
approximate  usefulness. 

It  should  be  noted,  first,  that  a  part  of  the  raw  calories  taken  in  as  food 
are  lost  to  the  metabolism,  in  that  organic  substances  of  definite  caloric 
value  are  excreted  unused  in  the  urine  and  feces.  The  sum  of  the  raw 
calories  is,  therefore,  greater  than  that  of  the  net  calories  which  serve  as 
the  physiologic  units  of  energy  for  growth  and  repair.  A  part  of  this  error 
in  reckoning  the  raw  calories  has  been  already  noted  (see  footnote  6). 
The  remainder  because  it  is  small  and,  in  the  healthy  child  at  least,  of 
slight  variability  is  a  negligible  quantity. 

In  the  second  place,  a  further  error  is  incident  to  the  fact  that  the 
caloric  requirement  is  estimated  by  body-weight  rather  than  as  the  theory 
strictly  demands — by  body  surface.7  This  really  important  error  is  dis- 
counted in  clinical  practice  by  the  fact  that  a  gradual  reduction  of  the 
caloric  requirement  is  adopted  corresponding  to  the  decrease  of  surface  as 
weight  increases. 

Attention  is  called  to  these  limitations  in  order  to  protect  the  caloric 
method  of  determining  food  requirements,  on  the  one  hand,  from  the  exces- 
sive enthusiasm  of  its  advocates  and  from  its  indiscriminate  application, 
and,  on  the  other  hand,  from  the  unjust  objections  of  its  critics.  Within 
these  limitations,  the  method  permits  us  to  determine  empirically  a  definite 
relation  between  body-weight  and  the  total  food  requirement  of  the  healthy 
child.  Heubner  has  designated  the  number  of  calories  which  a  normally 
growing  child  requires  during  the  successive  divisions  of  its  first  year  of 
life,  for  every  kilo  of  body-weight,  as  the  energy  quotient.  The  first  figures 
given  by  Heubner  were  based  upon  a  few  observations  only;  but  as  experi- 
ence has  added  to  the  sum  of  knowledge  these  figures  have  been,  again  and 
again,  corrected;  and  today  we  use,  in  round  numbers,  100  calories,  or  a 
little  more,  in  the  first  quarter  year  of  life;  90  calories  in  the  second;  80  in 

7  The  measurement  of  the  body  surface  is  an  extremely  difficult  task;  it  takes  a  long 
time  and  is  not  applicable  even  in  hospitals,  to  say  nothing  of  private  practice.  The 
calculation  of  the  surface  area  from  body-weight,  according  to  the  formula  of  Meeh, 
demands  a  mathematical  facility  which  is  hardly  to  be  expected  of  the  physician  and, 
therefore,  it  has  not  come  into  common  use. 


22  TEXT-BOOK  OF  PEDIATRICS 

the  third  and  70  in  the  fourth,  per  kilogram  of  body-weight.  For  human 
milk,  a  caloric  value  of  700  (650-750)  calories  per  litre  has  been  adopted. 
The  value  for  undiluted  cow's  milk  is  as  great.  The  caloric  value  of  various 
other  milk  mixtures  will  be  given  later  in  the  chapter  on  Artificial  Feeding. 

The  caloric  requirement  of  the  healthy,  artificially-fed  infant  does  not 
differ  greatly  from  that  of  the  breast-fed  child.  From  various  studies  it 
appears  that  its  demand  is  somewhat  larger  and  these  findings  have  been 
explained  by  the  fact  that  the  digestive  labor  is  greater  upon  artificial  food 
and  that  this  necessitates  an  increased  supply  of  food.  Results  recently 
reported  by  Engel  and  Samelson  do  not  agree  with  this  conclusion  and  it  is 
a  question  whether  other  factors  did  not  enter  into  the  earlier  observations; 
as,  for  instance,  the  greater  loss  of  useful,  but  unused  calories  in  the  feces 
and  urine;  or,  still  more  probably  the  less  favorable  nutritive  balance 
induced  by  the  greater  restlessness  of  the  artificially-fed  child. 

While  the  fact  that  the  total  metabolism  of  the  child  is  more  rapid  than 
that  of  the  adult  has  been  incontrovertibly  established,  the  rule  of  Rubner 
that  metabolism  and  food  requirement  are,  other  things  being  equal,  pro- 
portionate to  surface  area  has  not  gone  uncontradicted. 

Several  physiologists,  Magnus-Levy,  Sonden  and  Tigerstedt,  and  A. 
Loewy,  have  drawn  the  conclusion  from  their  researches  that  a  special 
increased  energy  is  present  in  the  infant  because  of  his  youth,  which  causes 
a  peculiar  excitability  of  the  heat-producing  agencies  and,  therefore,  an 
excessive  metabolism.  Schlossmann  and  Murschhauser  have  gone  over 
these  results  in  very  complete  metabolic  experiments  in  the  calorimeter, 
but  have  found  that  they  could  not  confirm  them  with  the  material  used. 
They  maintain  that  deviations  from  the  rule  laid  down  by  Rubner  are  due 
to  stiU  another  item,  that  of  less  economical  muscular  activity  in  the  infant. 

In  the  study  of  heat  production  in  approximately  normal  infants  from  19 
days  to  18  months  of  age,  Benedict  and  Talbot  found  an  average  resting 
heat  production  of  65  calories  per  kilogram  of  body-weight.  They  state 
that  "aside  from  a  slight  tendency  for  the  total  metabolism  to  be  larger 
with  increasing  weight,  no  regular  relationship  exists  with  infants  between 
the  total  heat  production  and  the  body  weight,  regardless  of  whether  the 
body-weight  was  actually  found,  computed  from  statistics  of  average 
values  for  normal  infants,  or  was  the  expected  body- weight  based  on  the 
birth  weight."  They  conclude  that  the  extent  of  metabolism  is  deter- 
mined neither  by  weight  nor  by  surface  area,  but  by  the  mass  of  active 
protoplasmic  tissue.  The  varying  amount  of  fat,  comparatively  inactive 
tissue,  may  influence  the  variations  of  caloric  requirement. 

The  requirements  of  the  child  for  specific  materials  are  similar  to  those 
of  the  adult.  Water,  salts  and  protein  serve  for  purposes  of  growth  and 
repair;  fats  and  carbohydrates  are  used  for  fat  deposits  and,  especially,  for 
combustion.  It  is  not  immaterial  to  the  organism  whether  this  necessary 
energy  is  supplied  exclusively  or  predominantly  by  fat  or  by  carbohydrate. 
In  the  total  absence  of  carbohydrates,  as  already  shown,  disturbances  of  the 
internal  metabolism  arise,  because  an  interaction  between  the  digestive 
products  of  the  carbohydrates  and  of  the  fats  is  necessary  to  complete  the 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES          23 

combustion  of  the  latter.  If  these  products  of  carbohydrate  digestion  are 
wanting,  the  acetone  bodies  remain  as  incombustible  end-products.  If, 
however,  fat  is  absent,  the  integrity  of  the  chemical  composition  of  the 
body  is  endangered,  as  is  shown  in  the  retention  of  abnormally  large 
quantities  of  water  in  the  tissues.  The  cause  of  this  water-retention  is  not 
known.  The  fact  that  the  glycogen  deposited  in  the  body  holds  two  to  three 
tunes  its  weight  of  water  is  not  a  sufficient  explanation,  since  the  amount  of 
glycogen  is  so  small.  The  harmful  influence  of  a  disproportionately  fatty 
or  carbohydrate  diet  is  important  clinically  only  when  it  has  continued 
unchangingly  for  some  time. 

Corresponding  to  its  more  active  metabolism,  the  infant  uses  more 
oxygen  and  excretes  more  carbon  dioxide,  although  the  difference  is  very 
small  when  the  exchange  is  calculated  not  in  ratio  to  body-weight,  but  to 
body  surface.  The  figures,  obtained  by  Schlossmann  and  his  assistants, 
of  12.85  gms.  of  oxygen  used  and  15.75  gms.  of  carbon  dioxide  excreted, 
per  hour,  per  square  meter  of  surface  area  in  the  resting  infant,  agree  with 
the  average  quantities  determined  by  Rubner  in  the  resting  adult. 

A  very  considerable  part  of  the  gaseous  metabolism  is  represented  in 
excretion  through  the  lungs  with  the  aqueous  vapor.  The  so-called  insen- 
sible perspiration,  according  to  a  table  by  Camerer,  Jr.,  is  about  1.3  to  1.7 
grams  per  kilo  per  hour  during  the  first  half-year;  about  twice  that  in  the 
adult.  These  averages,  however,  have  been  obtained  from  greatly  varying 
individual  determinations.  Thus,  for  instance,  an  infant  when  at  rest  may 
lose  only  2  to  3  grams  per  kilo  per  hour,  but  when  extremely  restless  it 
may  lose  from  10  to  15  grams  per  hour. 

GROWTH 

In  the  preceding  pages  so  much  stress  has  been  laid  upon  growth  as  a 
visible  phenomenon  in  the  life  of  the  infant  organism  that  it  seems  neces- 
sary to  treat  the  principle  of  growth  more  fully.  Aside  from  minor 
indices  of  growth,  of  interest  only  from  a  clinical  standpoint,  as,  for  instance, 
the  increase  of  the  circumference  of  the  head  and  chest,  to  be  discussed  in  a 
later  chapter,  growth  may  be  determined  by  measurement  in  two  ways: 
first,  as  weight  and,  second,  as  total  body  length. 

The  figures  cited  at  the  close  of  the  preceding  section  concerning  the 
volume  of  the  insensible  perspiration,  as  well  as  those  which  bear  upon  the 
capacity  of  the  stomach,  suggest  that  to  be  of  value  for  comparison  the 
child's  weight  must  be  taken  always  at  the  same  hour.  This  is  also  true 
for  the  measurements  of  length,  since  it  is  well  known  that  a  slight  decrease 
(1-3  cm.)  occurs  after  the  body  has  been  in  an  upright  position  during  the 
day.  The  disturbing  factor  of  variance  in  the  amount  of  the  stomach- 
content  is  best  avoided  by  weighing  the  child  immediately  before  the  first 
or  second  feeding  of  the  day. 

The  average  birth  weight  of  healthy  children  is  3400  gms.  (ll/2  pounds) 
for  boys,  and  3200  gms.  (7^  pounds)  for  girls.  Great  variations  from  these 
averages  are  possible  under  entirely  physiologic  conditions.  Usually  the 


24 


TEXT-BOOK  OF  PEDIATRICS 


first-born  children  are  smaller  than  those  of  later  birth.8  The  size  and 
weight  of  the  mother  do  not  always  determine  the  size  of  the  new-born  child 
at  full  term  and  great  variations,  in  both  directions,  often  occur.  This  is 
also  true  in  the  degree  of  development  of  the  subcutaneous  fat. 

The  average  weight  of  the  American  new-born  (white)  is  about  3.45 
kilos  for  boys  and  about  3.35  kilos  for  girls,  being  slightly  above  the 
European  average  usually  quoted.  Among  the  factors  affecting  the  weight 
of  the  new-born  are  sex,  activity  of  the  mother  in  the  last  weeks  of  preg- 
nancy, age  of  the  mother,  parity  and  race.  Most  of  these  factors  apparently 
influence  the  new-born  weight  through  their  effect  on  the  duration  of  preg- 
nancy rather  than  through  any  direct  influence  on  the  rate  of  growth. 
There  is  no  scientific  evidence  to  show  that  changes  in  the  nutrition  of 


Gervlcht 


7Z        15        20        ^tf        28 


Jff       W 


f.8      5Z. 


9000 


8000 


7000 


6000 


5000 


WOO 


3000 


FIG.  2. — Average  weight  of  breast-infants  weighing  more  than  2750  grams  (6|  pounds)  at  birth. 
(After  Camerer,  Sr.) 

the  human  mother,  within  ordinary  limits,  has  any  constant  effect  on  the 
weight  of  the  offspring. 

During  the  first  two,  three,  or  more  days,  all  new-born  infants  show  a 
physiologic  loss  of  weight  in  varying  amount,9  which  is  equalized  again, 
in  breast-fed  infants,  by  the  eighth  to  the  tenth  day.  Then  follows,  under 
normal  conditions,  a  continuous  gain,  which  may  be  interrupted,  as  shown 
hi  the  daily  weighings,  by  pauses  or  even  by  slight  losses,  but  which,  com- 
paring one  week  with  another,  indicate  an  almost  regular  rise. 

This  regularity  is,  of  course,  definite  only  in  individuals  of  undisturbed 
development.  As  soon  as  an  average  of  any  large  number  of  children,  who 
are  not  always  weighed  at  the  same  interval,  is  taken,  it  is  lost.  The  fol- 

8  To  this  is  supposedly  due,  in  part,  the  fact  that  the  material  of  lying-in  hospitals 
which  consists  largely  of  first-born  children,  shows  a  small  average  of  weight. 

9  This  physiologic  loss  amounts  to  200  gms.  (7  ounces)  or  more,  especially  in  chil- 
dren of  heavy  weight  at  birth. 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES 


25 


lowing  tables  were  obtained  by  the  elder  Camerer  from  the  study  of  119 
breast-fed  and  84  artificially-fed  infants,  of  more  than  2750  gms.  (6  pounds) 
birth  weight,  without  consideration  of  sex.  The  table  for  breast-fed 
infants  is  presented  in  the  form  of  a  curve,  so  that  it  may  be  the  more 
readily  studied. 

TABLE  I. 

Average  weight  during  the  first  year  of  children  weighing  more  than  2780  gms. 
(6.12  pounds)  at  birth. 

Abbreviated  from  the  table  of  Camerer,  Sr.  in  the  Jahrbuch  fur  Kinderheilkunde, 
Vol.  LIII,  pp.  409. 


End  of  Week 

Breast-fed  Infants 

Artificially-fed  Infants 

Grams 

Pounds 

Grams 

Pounds 

Birth  

3433 
3408 
3567 
3781 
4008 
4907 
5600 
5693 
6294 
6824 
7289 
7505 
7774 
8175 
8655 
8674 
8855 
9232 
9589 
10141 

7.55 

7.49 
7.85 
8.33 
8.83 
10.80 
12.33 
12.54 
13.63 
15.00 
16.05 
16.53 
17.12 
18.00 
19.06 
19.10 
19.50 
20.33 
21.12 
22.33 

3467 
3314 
3384 
3557 
3683 
4303 
4911 
5093 
5532 
6181 
6836 
7278 
7207 
7783 
8161 
8470 
8306 
8782 
9192 
9624 

7.64 
7.30 
7.45 
7.83 
8.15 
9.48 
10.82 
11.22 
12.18 
13.61 
15.05 
16.03 
15.87 
17.14 
17.97 
18.65 
18.29 
19.34 
20.25 
21.19 

1st            

2nd 

3rd     

4th      

8th                 

12th                         .    . 

13th     .    

16th     

20th         

24th  

26th     

28th     

32nd     

36th 

39th  

40th      

44th      

48th       .              

52nd 

These  figures  of  Camerer's  may  be  considered  rather  high  in  their 
absolute  values  and  indicative  of  a  stronger  tendency  to  growth  than  the 
average  in  these  children.  Every  physician  who  has  the  opportunity  to 
observe  different  types  of  children  frequently  meets  with  infants  who,  in 
spite  of  continuously  undisturbed  health  and  regular  development,  will  not 
come  up  to  these  figures.  Nor  is  the  curve  the  same  in  all  cases.  In  some, 
the  greater  increase  occurs  at  the  beginning,  while  a  gradual  flattening  of 
the  curve  is  evidenced  by  the  sixth  or  seventh  month;  in  others,  an  almost 
regular  advance  occurs  during  the  entire  first  year.  Between  these 
extremes  all  possible  transitional  forms  may  exist.  Further,  attention  must 
be  called  to  cases  in  whom  no  actual  increase  occurs,  during  the  first  weeks, 
because  of  a  slow  increase  in  the  quantities  of  breast-milk,  but  in  whom  the 
delay  is  fully  equalized  by  the  more  rapid  growth  of  following  months.  This 
is  the  best  of  evidence  that  a  long  continuance  of  even  scant  feeding  at  the 
breast  has  caused  no  lasting  injury  to  the  child. 

From  these  figures  it  may  be  seen  that  the  birth  weight  is  about 
doubled  by  the  beginning  of  the  fifth  month  and  is  trebled  by  the  close  of 


26 


TEXT-BOOK  OF  PEDIATRICS 


the  first  year.  The  differences  in  weight  between  boys  and  girls,  which  are 
not  shown  in  the  table,  gradually  become  greater,  being  from  200  grams 
(7  ounces)  to  500  grams  (18  ounces)  in  favor  of  the  boys  by  the  end 
of  the  twelfth  month. 

After  the  second  year,  the  weight  increase  is  markedly  slower.  The  fol- 
lowing table  gives  in  round  numbers  the  yearly  averages  and  also  the  sex 
differences  of  weight. 

A  number  of  formulae  have  been  developed  for  expressing  the  growth 
in  height  and  weight  during  childhood,  but  most  of  these  are  too  complex 
for  immediate  practical  application.  The  following  simple  rules  give 

TABLE  II. 
Increase  in  Weight. 


End  of  the  Year 

Boys 

Girls 

Body-  Weight 

Annual  Increase 

Body-Weight 

Annual  Increase 

Kilos 

Pounds 

Kilos 

Pounds 

Kilos 

Pounds 

Kilos 

Pounds 

Birth  

3.4 
10.2 
12.7 
14.7 
16.5 
18.0 
20.5 
23.0 
25.0 
27.5 
30.0 
32.5 
35.0 
37.5 
41.0 
45.0 
50.0 
56.0 

7.48 
22.44 
27.94 
32.34 
36.30 
39.60 
45.10 
50.60 
55.00 
60.50 
60.00 
71.50 
77.00 
82.50 
90.20 
99.00 
110.00 
123.20 

6.8 
2.5 

2.0 
1.8 
1.5 
2.5 
2.5 
2.0 
2.5 
2.5 
2.5 
2.5 
2.5 
3.5 
4.0 
6.0 
6.0 

14.96 
5.50 
4.40 
3.96 
3.30 
5.50 
5.50 
4.40 
5.50 
5.50 
5.50 
5.50 
5.50 
7.70 
8.80 
13.20 
13.20 

3.2 
9.7 
12.2 
14.2 
15.7 
17.0 
19.0 
21.0 
23.0 
25.0 
27.0 
29.0 
32.0 
37.0 
43.0 
48.0 
52.0 

7.04 
21.34 
26.84 
31.24 
34.54 
37.40 
41.80 
48.20 
50.60 
55.00 
59.40 
63.80 
70.40 
81.40 
94.60 
105.60 
114.40 

6.5 

2.5 
2.0 
1.5 
1.3 
2.0 
2.0 
2.0 
2.0 
2.0 
2.0 
3.0 
5.0 
6.0 
5.0 
4.0 

14.30 
5.50 
4.40 
3.30 
2.86 
4.40 
4.40 
4.40 
4.40 
4.40 
4.40 
6.60 
11.00 
13.20 
11.00 
8.80 

1st  

2nd     . 

3rd  

4th  

5th  

6th 

7th 

8th  

9th   ... 

10th 

llth  

12th  

13th  .    . 

14th  . 

15th 

16th  

17th  .... 

weights  and  heights  which  fall  within  the  range  of  normal  variation  from 
the  average  for  American  children. 

Height  (in  inches)  equals  twice  the  age  (in  years)  plus  32  inches  (good 
from  3  to  about  14  years). 

Weight  (in  pounds)  equals  seven  times  age  in  years  minus  2  pounds  for 
each  year  under  seven  (good  from  3  to  7  years). 

Weight  (in  pounds)  equals  seven  times  age  in  years  plus  4  pounds  for 
each  year  over  seven  (good  from  7  to  12  years). 

A  more  rapid  increase  of  weight  during  the  years  of  adolescence  is  very 
plainly  indicated  in  this  table  and  a  corresponding  rise  is  shown  in  the  table 
of  body  lengths.  Since  puberty  occurs  earlier  in  girls,  their  increases  during 
the  thirteenth  to  the  fifteenth  years  exceed  those  of  the  boys,  not  only 
relatively  but  absolutely.  During  the  succeeding  years  the  increase  is 
always  less. 


27. 

The  growth  in  length  corresponds  to  the  weight  increase,  in  so  far  as  it  is 
greatest  during  the  first  year  of  life  and  becomes  more  gradual  with 
advancing  age.  The  following  table  gives  the  yearly  averages  in 
round  numbers: 


TABLE  III. 
Growth  in  Height. 

End  of  the  Year 

Boys 

Girls 

Height 

Annual 
increase 

Height 

Annual 
Increase 

Cm. 

Inches 

Cm. 

Inches 

Cm. 

Inches 

Cm. 

Inches 

Birth  

50 
75 
85 
93 
99 
104 
109 
115 
120 
125 
130 
135 
140 
145 
151 
157 
164 
168 
170 

20.0 
30.0 
34.0 
37.2 
39.6 
41.6 
43.6 
46.0 
48.0 
50.0 
52.0 
54.0 
56.0 
58.0 
60.4 
62.8 
65.6 
67.2 
68.0 

25 
10 

8 
6 
5 
5 
6 
5 
5 
5 
5 
5 
5 
6 
6 
7 
4 
2 

10.0 
4.0 
3.2 
2.4 
2.0 
2.0 
2.4 
2.0 
2.0 
2.0 
2.0 
2.0 
2.0 
2.4 
2.8 
1.6 
0.8 

49 
74 
84 
92 
98 
103 
107 
113 
118 
123 
128 
133 
139 
146 
153 
158 
160 
161 

19.6 
29.6 
33.6 
36.8 
39.2 
41.2 
42.8 
45.2 
47.2 
49.2 
51.2 
53.2 
55.6 
58.4 
61.2 
63.2 
64.0 
64.4 

25 
10 
8 
6 
5 
4 
6 
5 
5 
5 
5 
6 
7 
7 
5 
2 
1 

10.0 
4.0 

3.2 
2.4 
2.0 
1.6 
2.4 
2.0 
2.0 
2.0 
2.0 
2.4 
2.8 
2.8 
2.0 
0.8 
0.4 

1st  :  

2nd  

3rd 

4th  

5th  

6th  

7th     

8th 

9th  

10th  

llth.  . 

12th 

13th  

14th  

15th  . 

16th  

17th 

18th  

Attention  should  be  called  to  the  fact  that  these  measurements  taken 
absolutely  are,  as  already  stated  of  the  table  of  weights,  rather  high  and 
that  measurements  which  do  not  come  up  to  them  are  still  within  the 
limits  of  normal  individual  variance. 

A  more  rapid  increase  in  girls,  both  relatively  and  absolutely,  during 
the  years  immediately  preceding  early  puberty  is  recognized.  During  the 
periods  of  sharply  accelerated  growth  the  child  is  commonly  said  to  "shoot 
up."  We  distinguish  such  a  period  during  the  first  year,  which  may  be 
looked  upon  as  a  continuance  of  the  rapid  fetal  growth;  a  second  stage 
appears  at  about  the  same  time  in  both  sexes,  in  or  near  the  seventh  year; 
and  a  third  acceleration,  dependent  upon  the  climax  of  puberty,  sets  in 
with  boys  from  the  fourteenth, to  the  sixteenth  year,  and  in  girls  from  the 
twelfth  to  the  fourteenth. 

Besides  these  variations  in  the  rate  of  increase,  alike  in  weight  and 
length,  dependent  upon  the  factor  of  age  in  children  after  infancy,  Mailing- 
Hanson  first  observed  variations  dependent  upon  seasonal  change.  These 
were  confirmed  later  by  the  elder  Camerer  and  by  Schmid-Monnard.  Three 
seasonal  periods  may  be  distinguished. 


28  TEXT-BOOK  OF  PEDIATRICS 

1.  The  period  from  the  middle  of  August  to  the  end  of  November  or 
middle  of  December,  the  last  third  of  the  year,  showing  the  greatest  increase 
in  weight  and  the  least  increase  in  length. 

2.  The  period  from  November  or  December  to  the  end  of  March,  or  the 
first  part  of  April,  the  first  third  of  the  year,  showing  a  moderate  increase 
in  weight  and  length. 

3.  The  period  from  the  end  of  March  or  the  beginning  of  April  to  the 
middle  of  August,  the  second  third  of  the  year,  exhibiting  the  greatest 
increase  in  length,  with  loss  of  weight. 

It  is  probable  that  different  modes  of  life  and  varying  activities  of 
children  in  the  several  seasons  cause  these  altered  relations  in  the  factors 
of  growth.  Whether  the  sedentary  habits  and  the  long  continued  in- 
door life  incident  to  attendance  at  school  play  an  important  part  is  not  en- 
tirely clear. 

The  unfavorable  influence  of  improper  food  and  unhygienic  surround- 
ings, as  indicated  by  the  greater  morbidity  and  the  greater  frequency  of 
the  severer  forms  of  rickets  among  the  poorer  classes,  is  suggested  also  by 
the  fact,  established  in  many  tables  of  statistics,  that,  as  a  rule,  the  children 
of  the  well-to-do  exceed  those  of  the  poor  both  in  weight  and  in  height. 
This  general  observation  does  not,  of  course,  exclude  far-reaching  individ- 
ual differences. 

The  relations  of  age,  weight  and  height  which  obtain  in  healthy  children 
have  been  presented  very  clearly  in  von  Pirquet  in  the  form  of  the  "meas- 
uring tape. " 

To  these  considerations  of  general  growth  should  be  added  some  em- 
phasis upon  the  incidents  of  special  growth. 

The  Brain. — The  average  weight  of  the  brain  at  birth  is  370  grams  in 
male  and  350  grams  in  female  infants,  while  the  adult  brain  weighs  from 
1260  to  1400  grams.  One-third  of  this  increase  (300-350  grams)  takes 
place  in  the  first  9  or  10  months  and  the  rest  of  the  increase  is  attained  by 
the  middle  of  the  third  year.  Roughly,  the  weight  of  the  brain  is  doubled 
by  the  end  of  the  first  year  and  tripled  at  two  and  one-half  years.  The 
growth  is  completed  by  the  16th  to  20th  years.  The  sexual  difference  in 
weight  of  10-15  grams  at  birth  becomes  greater,  so  that  in  adult  life  the 
brain  of  the  male  weighs  120  grams  more  than  that  of  the  female.  Normal 
average  weights  for  various  ages  are  approximately  as  follows: 

Grams 

New-born 370 

At  2  mos 460 

At  4-6  mos 600 

At  11-12"  mos 850 

At  2nd  year 970 

At  3rd  year 1100 

At  4th  year 1190 

At  5-8th  year 1220 

At  9-14th  year 1300 

At  15-20th  year 1400 

The  variations  in  normal  subjects  are  great  and  even  during  the  first 
year  may  be  100-200  grams.  There  is  no  noticeable  parallel  between  men- 
tal development  and  size  of  brain. 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES         29 

Skeletal  Growth. — The  centres  of  ossification  may  be  studied  in  the  liv- 
ing by  the  radiograph  and  are  of  clinical  interest. 

The  ossification  of  the  bones  of  the  wrist  is  of  particular  interest  ag 
indicating  the  physiologic  age  of  the  child.  All  of  the  bones  of  the  wrist 
are  commonly  cartilaginous  at  birth  although  one  and  sometimes  two  small 
ossification  centres  may  be  seen  in  particularly  well-developed  new-born 
children.  Two  centres  are  usually  present  at  1  year,  3  at  2  years,  4  at  3 
years,  5  at  4  or  5  years,  and  6  at  5  or  6  years.  The  ossification  of  the  wrist 
proceeds  more  rapidly  in  girls  than  in  boys,  the  former  being  a  full  year  in 
advance  of  the  latter  at  6  years. 

The  centres  appear  normally  in  regular  order,  subject  to  little  vari- 
ation. The  time  of  appearance  is  not  so  constant  that  the  exact  age  of  the 
child  can  be  determined  by  their  appearance.  Any  pronounced  delay  in 
the  development  of  the  ossification  centres,  however,  must  be  considered 
pathologic  and,  under  certain  circumstances,  as  pathognomonic.  It  is  not 
infrequently  combined  with  a  general  delay  of  the  growth  in  height. 

Of  the  fontanelles,  only  the  greater  or  anterior  is  normally  open,  that  is 
closed  only  by  a  membrane,  at  birth.  If  the  smaller  or  posterior  fontanelle 
at  the  juncture  of  the  sagittal  with  the  lambdoid  suture,  or  the  parietal 
fontanelles  between  the  temporal,  parietal  and  occipital  bones  are  still 
palpable  as  openings,  these,  as  well  as  the  open  condition  of  the  sutures, 
may  be  taken  as  evidence  of  retarded  ossification.  From  birth  to  its  com- 
plete closure,  which  occurs  during  the  first  half  of  the  second  year,  the 
greater  fontanelle  decreases  in  size  continuously.  Any  increase  in  area  is  to 
be  considered  pathologic  and  due  either  to  rickets  or  to  abnormal  growth  of 
the  head.  Complete  bony  occlusion  before  the  end  of  the  first  year  is  found 
only  in  conditions  where  the  growth  of  the  entire  head  is  abnormally 
retarded  (microcephaly).  There  is  great  variation  in  the  time  of  the  com- 
plete closure  of  the  anterior  fontanelle,  even  in  normal  children.  Collected 
statistics  show  that  the  structure  undergoes  but  little  change  in  size  in  the 
first  3  or  4  months  after  birth.  It  is  closed  in  about  15  per  cent,  of  all  cases 
at  one  year  and  in  about  50  per  cent,  at  15  months. 

Dentition. — 'The  physiology  of  dentition  has  always  been  of  great  interest 
to  the  physician.  For  hundreds  of  years,10  this  interest  was  inspired  entirely 
by  the  fact  that  the  causation  of  all  imaginable  diseases  of  the  first  years  was 
ascribed  to  dentition.  If  this  theory  which,  in  its  extreme  conclusions  has 
led  to  much  useless  interference  and  senseless  prescribing  and  in  its  actual 
disregard  of  disease  present  has  resulted  in  the  death  of  uncounted  numbers 
of  children,  could  be  completely  erased  from  the  minds  of  all  physicians  of 
today,  it  would  be  as  unnecessary  to  discuss  the  course  of  dentition  as  it  is 
to  discuss  growth  changes  in  the  bones  or  in  other  parts  of  the  body.  Since 
this  is  not  yet  true,  the  following  statement  may  be  presented. 

The  cutting  of  the  teeth  has  been  erroneously  considered  a  mechanical 
process  and  this  one-sided  consideration  of  the  growth  of  the  teeth  has  led 


10  We  must  thank  Ludwig  Fleischmann,  Clinic  of  Pediatrics,  Vol.  II,  Vienna,  1877, 
and  Kassowitz,  Diseases  During  the  Age  of  Dentition,  Leipzig  and  Vienna,  1892,  for 
interesting  clinical  and  historical  presentations  of  this  subject. 


30  TEXT-BOOK  OF  PEDIATRICS 

to  the  complete  oversight  of  the  coincident  growth  of  the  jaw.  Today, 
however,  we  know  that  most  marked  and  rapid  changes  take  place  shortly 
after  birth  and  that,  running  parallel  with  the  development  of  the  dental 
germ,  there  is  an  enlargement  of  the  jaw  and  a  gradual  resorption  of  the 
tissues  lying  above  and  beside  the  growing  tooth.  This,  curiously  enough, 
is  true  not  only  during  the  later  stages  of  development  when  the  tooth  has 
become  hard,  but,  also,  in  the  earlier  phases  when  the  tooth  is  but  a  soft 
sack  which  is  capable  of  exerting  only  slight  pressure. 

The  erupting  tooth  does  not  rupture  the  alveolus  any  more  than  the 
growing  epiphysis  ruptures  the  articular  cartilage  which  covers  it.  It  is 
rather  a  process  of  the  spreading  of  the  alveolus  for  the  tooth,  the  opening 
out  without  force  of  a  passage  for  it  under  the  gum.  The  soft  gum  tissue 
then  forms  its  only  barrier,  and  this  too  is  doubtless  overcome,  in  an  anal- 
ogous manner,  by  the  gradual  resorption  of  the  soft  parts  without  no- 
ticeable pain  and,  at  least  in  the  nervously  normal  child,  without  any 
disturbance  either  of  a  local  or  a  general  nature. 

This  does  away  with  any  physiologic  basis  for  the  teaching  of  difficult 
dentition.  In  its  place,  we  are  gaining  an  increasing  knowledge  of  the 
pathology  of  infancy  and  a  clearer  comprehension  of  the  nature  of  all  those 
disturbances  and  diseases  which  were  formerly  ascribed  to  it. 

A  knowledge  of  the  normal  course  of  dentition  is  of  importance  for 
another  reason;  that  is,  in  regard  to  the  time  of  the  successive  appearance 
of  the  several  groups  of  teeth.  First,  between  the  sixth  and  the  ninth 
months,  the  lower  central  incisors  appear;  a  few  weeks  later,  the  upper 
middle  incisors;  and,  in  rapid  succession,  the  upper  lateral  incisors.  The 
lower  lateral  incisors  appear  somewhat  later;  so  that  by  the  end  of  the 
first  year,  at  least,  all  of  the  eight  incisors  have  erupted.  Usually  several 
weeks  or  several  months  after,  the  premolars  appear,  first  above,  then 
below,  and  but  very  rarely  in  the  reverse  order;  and,  by  the  end  of  the 
second  year  of  life,  the  cuspids  come  through.  In  the  third  year  of  life, 
the  first  molars  finally  appear  and  with  these  twenty  teeth  the  temporary 
dentition  is  complete.  The  following  method  may  be  used  in  writing  the 
tooth  formula  of  a  child,  the  horizontal  line  representing  the  buccal  opening 
and  the  vertical  the  median  line. 


c' 

0 

b 

a' 

a 

a 

a' 

1) 

B 

c' 

c' 

c 

b 

a' 

a 

B 

a' 

b 

C 

c' 

Any  notable  extension  of  the  period  of  dentition  marked  by  longer 
pauses  between  the  eruption  of  the  several  teeth,  or  any  great  variation 
from  the  natural  order  in  which  the  teeth  appear  must  be  considered  as  an 
evidence  of  rickets. 

The  second  dentition  begins  with  the  eruption,  in  both  the  upper  and 
the  lower  jaw,  of  the  third  pair  of  molars  (six-year  molar) ;  then  the  milk 
teeth  gradually  drop  out,  in  about  the  order  of  their  appearance,  and  are 
replaced  by  the  teeth  of  the  permanent  set.  Just  before  the  beginning  of 
puberty  the  fourth  molars  erupt  and  finally  the  fifth  pair,  called  the  wisdom 
teeth,  because  they  usually  appear  sometime  after  puberty. 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES          31 

The  Nervous  System. — The  central  nervous  system  of  the  new-born  and 
the  young  infant  has  practically  the  same  form  as  that  of  the  adult.  When 
we  consider  that  the  brain  of  the  new-born  is  remarkably  heavy,  even  in 
comparison  to  the  total  body- weight  (about  1 : 8  at  birth;  in  the  adult  about 
1 : 40),  we  may  readily  understand  that  man  brings  into  the  world  with  him 
a  brain  which  is  laid  out  in  external  outlines  and  form  upon  a  remarkably 
large  scale,  but  the  interior  may  be  compared  to  an  unfinished  house.  The 
interior  is  not  hollow  or  empty,  nor  are  its  ventricles  larger  than  in  later 
life;  but  the  greater  part  of  its  mass  consists  of  unfinished  tissue  which 
apparently  serves  only  for  scaffolding  and  framework  and  which,  in  the 
course  of  later  development,  is  gradually  replaced  by  specific  nerve  tis- 
sue— ganglion  cells  and  nerve  fibres.  This  development  involves  not 
only  a  quantitative  increase  but  also  a  qualitative  change  from  the 
simpler  forms  resembling  embryonic  types  to  the  higher  differentiations 
which  mark  the  adult.  The  most  noticeable  difference  in  the  macroscopic 
comparison  of  the  infantile  and  the  adult  brain  and  spinal  cord  is  found  in 
the  development  of  the  myelin  sheaths. 

In  the  cord  of  the  infant  born  at  term  this  is  complete,  excepting  for  a 
small  remnant.  Only  the  directed  and  crossed  pyramidal  tracts  are  almost 
wholly  unmedullated.  The  cauda  equina,  the  medulla  and  the  cerebellum 
contain  numerous  medullated  tracts  even  at  birth;  while  only  a  few  fibres 
or  bundles  of  fibres,  in  the  cerebellum  and  preponderantly  in  the  projection 
system,  are  medullated.  Because  of  this,  the  entire  white  portion  of  the 
brain  appears  gray  upon  section,  being  only  slightly  differentiated  from  the 
gray  of  the  cortex.  Further  development  continues  progressively,  with 
slight  variations  of  rapidity  and  order  in  different  individuals,  one  bundle 
of  fibres  after  the  other  becoming  medullated. 

At  about  nine  months,  most  of  the  long  association  tracts,  with  the 
exception  of  the  projection  fibres,  are  medullated,  while  the  shorter  fibres, 
connecting  closely  neighboring  regions,  and  the  radiation  fibres  are  much 
slower  of  medullation  and  are  probably  not  completely  covered  and 
definitely  developed  by  the  end  of  childhood  or  the  period  of  com- 
pleted growth. 

The  brain  has  acquired  nearly  one-third  of  its  adult  weight  at  the  time 
of  birth  and  the  spinal  cord  about  one-seventh,  whereas  the  body  increases 
twenty-fold  in  weight  between  birth  and  maturity.  Approximately  two- 
thirds  of  the  postnatal  growth  of  the  brain  takes  place  in  the  first  18 
months  and  over  90  per  cent,  is  accomplished  by  6  years.  The  different 
parts  of  the  brain  grow  at  somewhat  different  rates,  the  cerebellum  and 
brain  stem  increasing  more  in  postnatal  life  than  the  cerebrum.  The 
primary  and  secondary  fissures  of  the  cerebrum  are  all  present  at  the  time  of 
birth  although  some  of  the  tertiary  ones  are  formed  during  the  first  month 
after  birth.  It  is  probable  that  all  of  the  nerve  cells  of  the  cerebrum  and 
cerebellum  are  formed  at  birth. 

The  peripheral  nerves  of  the  new-born  are  very  poor  in  covering  and 
where  neurilemma  can  be  distinguished  it  is  thin,  unequally  developed  and 
frequently  interrupted  by  non-medullated  areas.  The  medullation  proceeds 


32  TEXT-BOOK  OF  PEDIATRICS 

rapidly  during  the  first  few  weeks;  later  more  slowly,  and  is  completed  by 
the  end  of  the  first  year.  Other  histological  peculiarities  of  the  peripheral 
nervous  system  of  infants,  which  need  not  be  specifically  mentioned  here, 
also  disappear  by  the  end  of  this  period. 

Of  the  cranial  nerves,  the  optic  nerve  is  only  partly  medullated  at  birth 
and  in  the  region  of  the  cribriform  plate  is  entirely  unmedullated.  The 
medullation  proceeds  from  the  central  to  the  peripheral  end,  that  is  in  the 
reverse  of  the  direction  of  the  transmission  of  impulses  through  the  fibres. 
The  auditory  nerve,  on  the  contrary,  is  completely  covered  at  birth. 

The  anatomical  differences  in  the  sense  organs  to  which  attention  should 
be  called,  are  first,  the  eye,  which  is  hyperopic  in  the  new-born,  and  second 
the  middle  ear,  which  is  filled  with  mucous  fluid,  at  least  during  the  first 
few  hours  after  birth  and  sometimes  for  a  longer  period.  This  probably 
comes  from  the  amniotic  fluid.  The  condition  of  the  middle  chamber  might 
lead  us  to  suspect  a  temporary  deafness,  especially  when  we  consider,  as 
already  mentioned,  that  the  auditory  nerve  is  completely  formed  at  birth. 

To  attempt  a  description  of  the  psychic  development  of  the  child  from 
birth  to  puberty,  even  though  but  the  chief  points  were  to  be  touched,  would 
seem  an  impossible  task.  It  is  better  that  we  refer  to  the  works  of  Preyer, 
Compayre,  Ament  and  others,  where  many  references  to  the  literature  may 
be  found.  We  can  give  only  the  following  points: 

At  the  age  of  three  months,  after  the  so-called  stupid  quarter  of  the 
year,  the  infant  is  so  completely  in  control  of  all  his  senses  that  the  move- 
ments of  the  eyes,  incoordinate  at  first,  have  become  completely  balanced 
and  objects  which  are  not  too  small  and  lie  in  the  line  of  direction  of  the 
vision  will  be  fixed  and  followed.  Frequently,  images  which  the  child  has 
seen  before,  as  for  instance,  the  faces  of  his  parents,  are  recognized  and 
greeted  with  a  smile.  Similarly,  there  appears  a  tendency  to  turn  toward 
the  location  of  a  noise,  at  first  by  turning  the  head  and  later  by  turning  the 
eyes  also. 

Articles  which  the  infant  sees  or  which  are  laid  in  the  palm  of  the  hand 
are  grasped.  However,  even  up  to  the  fourth  month,  the  closing  of  the 
hand  is  accomplished  by  a  palmar  flexion  of  the  hand  as  a  whole.  But 
shortly  after,  as  evidence  of  purposeful  central  coordination,  the  closure 
of  the  hand  occurs  with  a  synchronous  dorsal  flexion.  During  the  fourth 
or  fifth  month,  active  grasping  motions  are  made. 

The  sense  of  smell,  temperature  and  pain  are  soon  much  better  devel- 
oped than  they  are  at  birth. 

Among  coordinated  muscular  movements,  the  lifting  of  the  head  is  the 
first  to  appear  when  the  child  is  laid  upon  its  abdomen;  and  this  position 
may  be  maintained  for  several  minutes.  At  a  slightly  later  period,  when  the 
child  sits  with  some  support,  the  head  is  held  erect  and  is  freely  turned  from 
side  to  side;  while  unsupported,  sitting  is  not  usually  possible  before  the 
sixth  month.  This  is  more  constant  in  its  date  of  development  than  the 
power  of  standing,  which  shows  great  individual  differences.  With  sup- 
port under  the  arms,  strong  children  will  stand  for  several  minutes  during 
the  fourth  or  fifth  month,  and  by  the  seventh  or  eighth  month  they  will 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES          33 

stand  if  they  can  hold  fast  to  something  with  the  hands.  However,  they 
sometimes  let  go  suddenly  and  fall  down.  Shortly  after  this  children,  with 
well-developed  static  function  begin  to  take  their  first  steps,  while  they  hold 
by  or  lean  against  the  furniture.  Children  remain  at  this  stage  for  a  longer 
or  shorter  time,  according  to  their  temperament,  before  they  dare  to  walk 
without  support.  This  is  usually  accomplished  between  the  tenth  and  the 
fifteenth  month. 

Delays  may  be  caused  by  disease,  especially  by  long-continued  illnesses 
which  disturb  the  entire  development.  More  frequently,  rickets  may  post- 
pone the  date  of  any  of  these  periods  of  progressively  acquired  function. 
Even  the  simple  muscular  stretching  and  the  power  of  standing  upon  the 
feet  which  normal  children  attempt  very  early  may  be  absent  until  late  in 
the  second  year.  These  children,  recognized  for  other  reasons  as  back- 
ward rickitics,  draw  the  legs  up  to  the  abdomen  when  they  are  lifted  by  the 
arms.  Standing  and  walking,  with  them,  may  be  delayed  until  the  third 
or  fourth  year. 

Marked  delay  in  the  development  of  coordinated  motor  function,  even 
in  the  matter  of  holding  up  the  head,  is  under  certain  circumstances  to  be 
considered  an  early  symptom  of  imbecility.  It  doubtless  depends,  in  the 
first  place,  upon  the  lack  of  attention  and  interest  in  the  surroundings  and 
is,  therefore,  to  be  considered  an  intra-psychic  rather  than  a  psychomotor 
defect.  This  is  further  shown  in  other  respects,  as  in  the  reduction  of  the 
pain  and  taste  senses  phenomena  of  absence  which  can  be  demonstrated  at 
one  and  the  same  time  and  can  be  explained  in  no  other  way. 

The  first  motions  of  the  new-born  are  in  part  automatic  and  in  part 
reflex.  This  is  true,  not  only  of  the  complicated  coordinated  motions,  such 
as  suckling,  but  also  of  the  mimic  motions  of  expression. 

It  is  a  well-known  fact  that  the  new-born  infant  reacts  to  stimulation 
of  the  taste  organs,  by  placing  upon  the  tongue  sweet,  sour,  salty  or  acid 
substances,  by  corresponding  facial  expressions.  That  these  responses  are 
brought  about  by  reflex  (subcortical)  action,  without  psychical  correlation 
is  shown  by  the  fact  that  hemi-  and  anencephalic  infants  in  whom  the  cere- 
brum, the  entire  organ  for  psychic  function,  is  absent,  show  the  same  re- 
sponsive power. 

It  is  very  interesting  to  note  how  the  subcortical  reflexes  disappear  in 
the  course  of  the  first  year  or  are  rather  replaced  by  cortical  action.  This 
explains  the  fact  that  the  facial  mimicry  is  often  absent  in  older  idiots. 
Their  subcortical  reflex  is  lost,  but  the  cortical  action  has  not  developed 
because  of  the  central  defect. 

The  same  condition  is  seen  in  the  sucking  reflex.  In  the  first  weeks,  it 
appears  unconditionally  every  time  the  lips  or  the  neighboring  region  re- 
ceive a  sufficient  stimulus,  but  later  it  occurs  only  when  the  child  is  hungry 
or  is  waiting  for  a  feeding  or  the  like,  and  then  as  a  conditional  reflex. 

The  light  reflex  and  the  corneal  reflex  are  completely  developed  in  the 
new-born,  while  the  reaction  of  the  pupil  for  accommodation  appears  in  the 
second  month.    The  blinking  reflex,  excited  by  the  rapid  approach  of  an 
object  to  the  eye,  first  appears  in  the  second  or  third  month. 
3 


34  TEXT-BOOK  OF  PEDIATRICS 

It  must  be  noted  that  Babinski  's  phenomenon  (the  dorsal  flexion  of  the 
toes,  and  especially  of  the  great  toe,  and  the  spreading  of  the  toes  when  the 
sole  of  the  foot  is  tickled)  is  physiologic  even  to  the  second  year. 

The  skin  reflexes,  frequently  absent  in  the  new-born,  are  usually  very 
active  in  older  infants. 

The  lachrymal  secretion  is  absent  during  the  first  few  months.  The 
tendon  reflexes  are  active  in  the  new-born,  as  well  as  in  older  infants,  and  are 
easily  brought  out  when  the  limbs  are  relaxed  as  during  the  act  of  nursing. 
At  other  times  they  are  masked  more  or  less  completely  by  the  physiologic 
hypertonia  of  the  muscles.  It  is  not  easy  to  explain  the  condition  upon 
which  this  "hypertonia,"  a  distinctly  increased  resistance  to  passive  mo- 
tion, depends.  It  is  a  readily  recognized  stiffness  and  awkwardness  of  all 
active  movements  in  the  extremities  of  the  new-born  which  exceeds  the 
hypertonia  of  later  infancy.  That  the  muscle  of  the  new-born  animal  does 
not  respond  to  a  nervous  stimulus  with  lightning-like  rapidity,  but  reacts 
with  a  more  gradual  and  more  or  less  tonic  contraction — a  fact  discovered 
by  Soltmann,  has  probably  something  to  do  with  it,  but  the  mechanism  of 
the  fact  is  far  from  clear. 

Physiologic  spasmophilia,  in  the  sense  of  an  increased  excitability  of  the 
reflexes  (Soltmann)  exists  neither  in  the  new-born  nor  in  older  infants. 
Nor  is  the  remarkably  frequent  occurrence  of  clonic  and  tonic  convulsions 
at  a  definite  period  of  infancy,  chiefly  during  the  second  and  third  semesters 
of  life,  dependent  so  much  upon  any  physiologic  peculiarities  of  the  infan- 
tile nervous  system  as  upon  special  disturbances  of  metabolism  incident  to 
that  age.  (See  chapter  on  Spasmophilia.) 

The  acquirement  of  speech,  to  which  a  certain  degree  of  intellectual 
development  is  necessary,  is  timed  rather  closely.  The  child  shows  an 
understanding  of  words  and  simple  sentences  at  about  one  year  of  age  and 
soon  after,  say  at  about  one  year  and  three  months,  begins  to  speak.  Even 
earlier,  usually  between  the  sixth  and  eighth  months,  the  child  exercises 
the  mechanism  of  articulation  with  easy  syllables,  preparing  for  the  func- 
tion of  speech.  Such  periods,  however,  are  subject  to  great  variations,  in 
part  due  to  the  inherent  conditions  of  the  child  itself  and  in  part  to  its 
environment.  They  may  be  markedly  delayed  without  the  presence  of 
any  mental  defect.  Such  defect  should  be  suspected  only  when  the  attain- 
ment of  speech  is  delayed  until  the  third  or  fourth  year. 

The  further  development  of  speech  and  the  exercise  of  the  mental 
faculties  varies  so  greatly,  even  in  children  of  similar  or  nearly  similar 
intrinsic  quality,  under  differing  environment,  that  it  is  not  as  yet  possible 
to  establish  any  definite  criterion  which  would  be  useful  in  judging  the 
milder  grades  of  mental  deficiency.  Long  continued  disease,  conditions  of 
exhaustion,  and  especially  defect  of  sense  organs,  may  delay  the  acquire- 
ment of  speech  and  the  exercise  of  mentality,  but  a  definite  prognosis  of 
future  development  is  entirely  impossible.  In  the  healthy  child  differences 
in  temperament  are  often  noticeable  at  an  early  period,  even  in  the  first  or 
second  year,  but  in  these,  even,  the  influence  of  intentional  and  unconscious 
training  is  very  great. 


ANATOMIC  AND  PHYSIOLOGIC  PECULIARITIES 


35 


The  sleep  of  the  infant  is  normally  sound  and  long  continued.  Healthy 
infants,  during  the  first  few  months,  sleep  nearly  all  day,  excepting  when 
being  fed  or  bathed  or  changed,  and 
when  asleep  assume  the  position 
shown  in  Fig.  3,  which  is  evidently 
a  continuation  of  intra-uterine  pos- 
ture. It  is  usually  an  indication  that 
the  child  is  ill  when  the  arms  sink 
to  the  sides.  The  length  of  time 
spent  in  sleep  is  gradually  decreased, 
from  about  twenty  hours,  by  occa- 
sional periods  of  wakefulness,  but 
even  during  the  third  to  the  sixth 
year  the  child  still  sleeps  twelve  to 
fifteen  hours  and  at  school  age  from 
nine  to  eleven  hours. 

FIG.  3. — Position  of  healthy  infant  during  sleep. 

Puberty,  the  period  of  the  de- 
velopment* of  the  genital  functions  and  of  the   secondary  sexual  char- 
acteristics, gradually  leads  up  to  maturity  and  does  not  actually  belong 
to  childhood. 


II.  CARE  AND  FEEDING  OF  THE  NORMAL  INFANT 

REVISED  BY 

JULIUS  HESS,  M.D., 

Professor  and  Head  of  the  Department  of  Pediatrics,  University  of  Illinois,  College 

of  Medicine,  Chicago. 

THE  science  of  the  feeding  of  children  and  especially  of  infants,  the 
differentiation  of  normal  from  pathological  conditions,  and  a  strict  discrim- 
ination of  what  should  be  considered  normal  is  more  important  in  this 
than  in  any  other  division  of  pediatrics.  The  indefinite  understanding  of 
normality,  the  recognition  or  non-recognition,  for  instance,  of  constitutional 
anomalies  even  in  the  infant,  the  designation  of  nutritive  results  as  satisfac- 
tory when  we  have  only  succeeded  in  causing  a  great  increase  in  weight  and 
large  deposits  of  fat,  have  proved  to  be  sources  of  serious  error  prejudicial  to 
the  science  of  pediatrics.  In  their  Manual,  Czerny  and  Keller  define  a 
new-born  child  as  healthy,  "when  it  is  born  of  healthy  parents  in  the  inid- 
productive  period,  when  it  is  carried  to  full  term,  is  free  from  essential 
malformities,  and  is  able,  with  the  protection  of  non-conducting  clothing,  to 
maintain  a  normal  body  temperature."  They  further  designate  that 
method  of  feeding  as  suitable  for  a  healthy  child  "by  which  the  child  devel- 
ops normally  in  body  and,  so  far  as  this  depends  upon  food,  psychically, 
and  remains  free  from  disturbances  of  metabolism,  as  well  as  of  those 
diseases  the  occurrence  of  which  is  influenced  by  disorders  of  nutrition." 
Only  a  strict  adherence  to  these  definitions  has  put  an  end  to  the  former 
chaos  in  the  teaching  of  infant-feeding. 

In  the  future,  whoever  tries  a  favorite  infant-food  upon  a  number  of 
children,  without  considering  whether,  in  the  strict  sense,  they  are  well  or 
ill;  and  who  attempts  to  draw  conclusions  of  the  values  or  non- value  of  a 
feeding  method  by  such  means,  shows  that  the  entire  progress  of  modern 
pediatrics  has  passed  him  by  without  leaving  any  impression. 

a.  NATURAL  FEEDING 

The  only  natural  food  for  the  infant,  during  the  first  half  year,  at  least, 
is  the  mother 's  milk.  To  what  extent  this  may  be  replaced  by  the  milk  of 
other  women  will  be  stated  later.  It  is  sufficient  here  to  call  attention  to  the 
fact  that  so-called  artificial  feeding  should  never  be  considered  natural 
feeding  for  children  of  this  age. 

OBSTACLES  TO  NURSING 

Before  we  describe  breast  feeding,  the  following  question  must  be 
settled.  Can  all  new-born  children  be  nursed  by  the  mother?  This  must  be 
answered  in  the  negative.  There  are  doubtless  obstacles  to  nursing  upon 
the  part  of  the  mother  and  upon  the  part  of  the  child,  but  they  are  much 
more  rare  than  is  generally  believed,  even  by  physicians. 
36 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT         37 

All  diseases  of  the  mother,  whether  they  are  connected  with  the  process 
of  giving  birth  to  the  child,  or  whether  they  be  of  an  infectious  or  constitu- 
tional nature,  are  only  conditional  obstacles.  Since  the  feeding  of  the 
child,  at  least  during  the  first  period  of  life,  requires  only  small  quantities  of 
mother's  milk,  the  supply  makes  no  special  demand  upon  the  physical 
strength  of  the  mother.  Further,  lactation  is  in  many  respects  necessary  to 
her  own  health.  The  physician  should  not  always  look  upon  severe  acute 
diseases,  as  eclampsia  and  nephritis  or  pneumonia,  as  reason  to  discontinue 
nursing.  Especially  is  nursing  not  contraindicated  under  conditions, 
involving  even  large  loss  of  blood  in  parturition,  which  give  promise  of  the 
comparatively  rapid  recovery  of  the  mother.  On  the  other  hand,  marked 
puerperal  sepsis,  typhoid  fever,  severe  erysipelas,  and  the  like,  make  nursing 
impossible  because  they  mean  danger  to  the  child.  Similarly,  malignant 
diabetes  and  epilepsy,  with  numerous  crises,  are  contraindications. 

For  want  of  experience  unimpeachably  beyond  the  contradiction  of 
critics,  views  are  divided  as  to  the  propriety  of  a  tuberculous  mother  nursing 
her  child.  While  formerly  nursing  was  absolutely  forbidden  in  every 
definite  case  of  tuberculosis,  a  view  Czerny  and  Keller  take,  this  is  con- 
tradicted by  Schlossmann,  who  bases  his  argument  upon  the  favorable 
influence  of  lactation  upon  the  health  and  weight  increase  of  the  mother,  as 
well  as  upon  the  greater  resistance  of  the  breast-fed  child  to  tuberculous 
infection.  This  claim  seems  to  be  supported  by  several  clinical  observations. 
Still  later  (Deutsch,  Tuberculosis  and  Nursing,  Munchner,  Medizinische 
Wochenschrift  1910,  page  1335)  facts  have  been  reported  on  the  other  side, 
under  rather  meagre  observations,  which  indicate  that  the  mother  with 
distinct  tuberculous  pulmonary  disease  should  be  absolutely  prohibited 
from  nursing,  for  her  own  benefit  as  well  as  for  that  of  the  child ;  while  in 
mothers  with  suspicious  changes  it  may  be  permitted  only  as  an  experiment 
under  the  observation  of  a  physician.  A  positive  von  Pirquet  reaction 
without  physical  lung  findings,  has  never  seemed  to  us  sufficient  reason  to 
discontinue  nursing  or  to  interrupt  it  without  mature  consideration. 

General  weakness,  anemia  and  emaciation,  extreme  youth,  and  in  most 
cases,  even  a  neuropathic  constitution,  are  not  adequate  causes  for  the 
initial  prohibition  of  nursing. 

The  majority  of  such  women  not  only  bear  the  added  strain  of  nursing, 
but  receive  undeniable  benefit  to  their  own  health  which  is  not  confined  to 
the  better  and  more  complete  involution  of  the  puerperal  organs — a  well- 
known  result,  but  manifests  itself  in  the  rarity  with  which  carcinoma  of  the 
breast  occurs  in  women  who  have  nursed.  No  prediction  can  be  made  in  the 
individual  case  as  to  whether  the  woman  will  lose  or  gain  in  weight  while 
nursing.  More  usually  the  mother  gains  in  weight,  and  hand  in  hand  with 
this  gain  comes  more  blooming  health,  an  increase  of  strength  and  an  im- 
provement in  her  general  well-being.  Loss  of  weight  is  not  in  itself  a  cause 
for  anxiety,  for  the  mother  may  be  placed  under  treatment  and  the  child 
may  be  weaned  at  any  time. 

Bearing-down  pains  in  the  breast  or  back,  sometimes  present  at  the 
beginning  of  lactation,  or  appearing  after  getting  up  are  usually  dissipated 


38  TEXT-BOOK  OF  PEDIATRICS 

by  suggestive  treatment,  as,  is  my  experience,  is  the  rare  tenderness  of 
the  nipples  in  neuropathic  women. 

More  serious  difficulties  are  presented  by  fissures  in  the  region  of  the 
nipples  because  of  the  severe  pain  which  some  women  suffer  and  because 
of  the  danger  of  mastitis.  Their  appearance  is  not  always  preventable, 
even  by  the  massage  of  the  nipples  with  spiritous  solutions  which  is 
frequently  recommended  during  the  last  months  of  pregnancy. 

Skill  in  placing  the  child  to  the  breast,  so  that  it  sucks  from  the  entire 
areola  and  not  from  the  nipple  alone  and  the  avoidance  of  too  long  periods 
of  feeding  are  probably  the  most  successful  preventatives. 

The  milder  cases  of  fissured  nipple  are  relieved  by  various  methods  of 
treatment.  Glycerin,  or  glycero-tannin  (5-10  per  cent.) ;  or  the  so-called 
"black  salve"  (silver  nitrate  0.1,  Balsam  Peru  1.0,  petrolatum  10.0),  or 
napthalin  ointment;  or  an  antiseptic  drying  powder  (bismuth  subgallate, 
or  the  like),  applied  between  feedings  and  removed  before  putting  the  child 
to  the  breast,  give  opportunity  for  the  reformation  of  epithelium.  Anesthesin 
ointment  (5  per  cent.),  may  be  used  to  allay  pain  or,  better  still,  a  solution 
of  silver  nitrate  (3-5  per  cent.),  may  be  used.  The  latter  causes  an  anes- 
thesia of  long  duration  after  the  short  initial  pain  and  repair  occurs  rapidly 
under  the  crust.  In  addition  to  these  methods,  it  will  be  found  necessary 
to  bind,  up  the  breasts  and  to  empty  them  frequently  by  nursing  or  ex- 
pression. This  may  be  done  either  completely,  three  or  four  times  daily 
or  by  removing  small  quantities  frequently.  A  nipple-shield  of  glass 
with  rubber  nipple  may  be  used  in  exceptional  cases,  but  the  abuse  of 
this  device  will  be  treated  later.  Only  rarely  do  these  methods  fail  to  give 
relief, -so  that  in  few  cases,  and  especially  in  hypersensitive  women,  nursing 
has  to  be  discontinued. 

Cases  of  mastitis  should  be  treated  surgically  with  ice-bags,  or  with 
warm  moist  applications,  or  by  carefully  applied  hyperemia.  Later,  radial 
incisions  which  do  not  enter  the  mammilla,  may  be  made  as  soon  as  the  pus 
is  localized,  followed  by  expression  from  the  incisions. 

With  this  treatment  we  must  provide  for  the  same  satisfactory  emptying 
of  the  breast  as  in  fissures,  both  for  its  beneficial  effect  by  reduction  of 
pressure  upon  the  circulation  and  to  prevent  the  arrest  of  the  secretion. 
This  emptying  may  be  accomplished  by  putting  the  child  to  the  breast 
without  hesitation,  since,  supported  by  numerous  experiences,  the  admix- 
ture of  even  large  amounts  of  infected  pus  with  human  milk  is  not  dan- 
gerous to  the  healthy  infant. 

By  this  means  it  is  possible,  in  most  instances,  if  the  inflammation  is  not 
of  a  phlegmonous  type  and  inclusive  of  the  entire  breast,  to  combine  the 
recovery  from  the  inflammatory  process  with  the  preservation  of  function. 
The  secretion  of  the  unaffected  breast  does  not  suffer  and  in  case  of  necessity 
may  be  increased  to  such  a  degree  that  its  output  will  be  sufficient  for 
many  months  of  lactation. 

The  form  of  the  breast  and  nipple  makes  the  first  attempt  at  nursing 
difficult  or  easy.  Distinctly  retracted  nipples,  rather  rare,  but  which 
may  occasionally  occur  on  both  sides,  may  be  an  absolute  obstacle  to 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT 


39 


nursing.1  Very  flat,  short  nipples  increase  the  difficulty  of  nursing,  but  do 
not  make  it  impossible. 

The  only  absolute  and  continuing  obstacle  to  nursing  upon  the  part  of 
the  child  is  a  cleft  palate.  In  children  who  are  born  weak  or  who  have  suf- 
fered considerably  in  the  process  of  birth  and  have  passed  the  first  few  days 
in  a  sort  of  comatose  condition,  nursing  may  be  very  difficult  and,  in  certain 
cases  and  for  the  first  few  days,  at  least,  may  be  impossible.  In  such  cases, 
where  suckling  is  temporarily  precluded,  the  breast  must  be  emptied  arti- 
ficially and  normal  nursing  delayed.  The  expressed  or  pumped  mother's 
milk  may  be  given  the  child  by  teaspoon  or  by  means  of  a  pipette  through 
the  mouth  or  nose. 

In  severe  coryza,  with  marked  swelling  of  the  mucous  membrane,  the 


FIG.  4. — First  position.  FIG.  5. — Second  position. 

Direct  expression  of  milk. 

application  of  epinephrin  solution  (1 : 3000)  may  relieve  the  difficulty.  Con- 
genital syphilis,  frequently  the  cause  of  such  snuffles,  is  never  a  reason  for 
prohibiting  the  nursing  of  the  child  by  its  own  mother  since  infection  from 
infant  to  mother  is  impossible. 

THE  ABILITY  OF  THE  MOTHER  TO  NURSE 

Up  to  this  point,  we  have  not  raised  the  question  whether  there  is  always 
milk  in  the  mother's  breast.  This  question  of  the  physical  ability  of  the 
mother  to  nurse  her  infant  is  of  general  interest. 

Comparing  the  reports  of  the  large  lying-in  hospitals,  according  to  which 
almost  100  per  cent,  of  all  women  confined  there  are  able  to  feed  their 
children  adequately,  at  least  during  the  first  nine  to  eleven  days  of  the 

1  In  this  case  the  milk  secretion  is  to  be  maintained  by  regular  expression  which 
can  be  accomplished  throughout  the  period  of  lactation. 


40  TEXT-BOOK  OF  PEDIATRICS 

puerperium,  with  the  experiences  of  private  practice,  in  which  a  certain 
per  cent,  of  all  women  either  do  not  attempt  to  nurse  or  give  up  the  attempt 
after  a  short  time,  because  of  the  alleged  lack  of  milk,  we  might  arrive  at 
the  conclusion  that  the  ability  to  nurse  differs  widely  in  the  various  social 
strata.  Whether  this  is  actually  so  or  not  cannot  be  determined,  because 
the  ability  or  the  lack  of  ability  to  nurse  is  not  a  definite  and  unchanging 
fact,  but  rather  a  relative  condition  dependent  upon  many  other  factors 
besides  the  anatomic  and  physiologic  structure  of  the  gland.  This  has  been 
often  shown  by  the  experience  of  many  institutions  when,  as  a  result  of  a 
change  in  medical  direction,  the  ability  to  nurse  has  enormously  increased, 
a  fact  which  teaches  us  to  recognize  the  influence  of  their  surroundings  upon 
young  mothers.  Anxiety  for  the  health  of  the  mother  and  doubt  of  her 
ability  to  nurse  may,  from  the  first,  weaken  her  desire  to  overcome  the 
difficulties  which  present  themselves.  To  strive  by  personal  influence  over 
the  mother  and,  as  a  teacher  of  midwives  and  nurses,  for  the  increase 
of  nursing-power  among  all  classes  of  the  women  offers  a  grateful  task  to 
every  physician. 

Cases  in  which  the  breast  of  the  puerperal  woman  altogether  fails  of 
secretion  are  so  extremely  rare  that  they  are  of  no  practical  importance.  The 
real  question  to  be  met  is  whether  we  may  expect  an  adequate  secretion. 
Frequently,  this  can  be  determined  neither  before  nor  shortly  after 
delivery,  for  the  rapidity  with  which  lactation  commences  differs  widely  in 
individuals.  As  a  rule,  it  is  slower  in  primiparse  than  in  women  who  have 
nursed  before.  Often  it  is  impossible  to  express  even  a  drop  from  the 
breast  for  the  first  two  days  and  yet  the  milk  secretion  shortly  becomes  suf- 
ficient if  the  child  is  placed  to  the  breast  regularly  and  suckles  strongly. 
We  must  admit  that  there  are  women  whose  breasts  do  not  functionate  nor- 
mally and  whose  power  of  lactation  remains  inadequate,  especially  if  the 
child  does  not  nurse  energetically  and  does  not  empty  the  breast  completely. 

The  physiologic  increase  of  lactation  power,  which  may  drag  along  for 
weeks  in  women  whose  breasts  do  not  secrete  freely,  should  be  remembered  in 
attempting  to  judge  the  value  or  the  non-value  of  the  various  galactagogues. 
Up  to  the  present  time  all  the  preparations  which  have  been  praised,  with 
more  or  less  clamorous  advertising,  as  "milk  producers  "  (somatose, 
sanatogen,  malt-tropon,  lactagol,  etc.),  are  no  more  specific  for  the  mam- 
mary gland  than  are  excessive  amounts  of  liquid  (soups,  milk,  etc.),  or 
solid  foods.  The  inefficiency  of  such  agents  is  shown  in  the  fact  that  while 
in  some  cases  no  physiologic  increase  of  the  lactation  power  occurs  or 
becomes  adequate  under  forced  feeding  for  a  considerable  period  of  time, 
yet  in  these  very  cases  a  continued  and  complete  emptying  of  the  breast 
gradually  accomplishes  its  desired  result.  The  recommendations  given  in 
good  faith  by  physicians  concerning  the  results  obtained  by  the  use  of 
various  galactagogues  given  them  for  trial,  are  not  testimonials  to  the 
scientific  knowledge  of  such  men.  Galactagogues  should  be  used  only  for 
the  psychic  support  they  may  add  to  other  means  advised  by  the  physician. 

The  fact,  which  may  now  be  considered  firmly  established,  that  the 
relation  between  the  mammary  gland  and  the  reproductive  organs,  in- 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT    41 

eluding  the  placenta,  is  not  a  nervous  one,  but  rather  one  of  chemically 
active  substances  of  the  hormone  type,  present  in  the  blood,  suggests  that 
the  time  is  approaching  when  specific  galactagogues  will  be  isolated  and 
adapted  to  therapeutic  use.  Very  suggestive  experiments  in  this  direction 
have  been  reported  by  Basch. 

Spontaneous  failure  of  lactation  is  certainly  extremely  rare  and  prob- 
ably always  occurs  in  consequence  of  an  incomplete  emptying  and  an 
insufficient  stimulation  of  the  breast,  as  in  cases  where  the  child  is  weak  and 
does  not  nurse  properly.  This  is  shown  by  the  fact  that  this  failure,  fre- 
quently reported  by  the  laity  in  private  practice,  is  never,  or  hardly  ever 
seen  in  institutions  conducted  by  physicians.  In  spite  of  the  reappearance 
of  the  menses,  the  normal  duration  of  a  well  established  lactation  is  almost 
unlimited  and  may,  if  a  new  conception  does  not  occur,  continue  for  several 
years  in  women  of  our  race  as  well  as  in  those  of  uncivilized  peoples. 

Eppstein  's  interesting  case,  in  which  a  wet-nurse  after  a  continued  lac- 
tation of  over  a  year,  undertook  the  nursing  of  the  next  child  of  the  same 
family  without  interruption  and  with  the  best  results  is  by  no  means  unique. 
It  shows  that  the  milk  of  so  "old"  a  nurse  may  be  used  for  anew-born 
babe.  This  fact  of  the  theoretically  unlimited  duration  of  lactation  is  but 
rarely  made  use  of  in  practice,  because  we  have  to  recommend  complete 
weaning  by  the  ninth  month  or,  at  least,  by  the  end  of  the  first  year,  for 
reasons  which  will  be  discussed  later. 

THE  HYGIENE  OF  THE  NURSING  MOTHER 

The  nursing  woman  should  change  her  mode  of  living  as  little  as  possible, 
avoiding  only  harmful  excesses  both  of  work  and  idleness.  Special  atten- 
tion should  be  directed  to  this  with  women  of  the  well-to-do  classes  and  with 
wet-nurses.  So  far  as  work  is  concerned,  observations  among  the  poor  have 
shown  that  even  a  large  amount  of  daily  work  in  house  or  factory  is  borne 
without  injury  to  the  health,  or  to  the  secretion  of  milk  of  the  constitu- 
tionally healthy  nursing  mother. 

Psychic  excitement,  especially  anger,  pain,  sorrow,  etc.,  have  no  influ- 
ence upon  the  qualitative  or  quantitative  condition  of  woman 's  milk.  The 
sudden  stopping  of  the  flow  of  milk,  supposedly  suffered  under  such  con- 
ditions in  especially  sensitive  women,  is  a  psychic  reflex  and  probably 
depends  mainly  upon  the  closure  of  the  sphincter  of  the  mammilla,  which 
temporarily  prevents  the  flow  or  makes  the  emptying  of  the  breast  more 
difficult.  It  may  be  gradually  overcome,  in  every  instance,  by  putting  the 
hungry  child  to  the  breast  at  regular  intervals.  The  idea  of  the  so-called 
toxic  effect  of  milk  supposed  to  be  sensitized  by  such  circumstances  should 
be  relegated  to  the  realm  of  the  fable. 

The  nursing  woman  should  take  a  sufficient  amount  of  suitable  nourish- 
ment, but  should  not  limit  herself  to  any  particular  diet.  Nothing  should  be 
prohibited  that  agrees  with  her.  She  may  eat,  without  fear  for  the  con- 
sistency of  her  milk,  not  only  spices  and  sour  foods,  but  also  lettuce,  raw 
fruits,  etc.,  with  freedom,  because  in  these  foods  the  elements  essential  to 
the  physiologic  growth  of  the  child  are  contained  in  larger  quantities  than 


42  TEXT-BOOK  OF  PEDIATRICS 

in  many  others.  In  women  with  small  appetites  as  variable  a  diet  as 
possible  is  to  be  recommended,  while  for  those  having  a  tendency  to  con- 
stipation it  is  well  to  give,  instead  of  a  largely  milk  and  soup  diet,  foods 
yielding  a  large  bulk  of  debris. 

The  quality  of  the  milk,  especially  as  to  its  fat  content,  varies  in  only 
slight  and  practically  unimportant  degree  in  any  individual  and  cannot 
be  influenced  by  the  diet  of  the  mother.  Particular  exceptions  (Moll) 
are  not  proof  against  the  argument  for  this  view,  when  we  consider  that 
the  child  itself  can  regulate  the  quantity  of  food  which  it  gets  from  the 
breast  (Gregor). 

Excessive  eating  and  drinking,  especially  of  such  foods  as  milk  and  rich 
soups,  do  not  lead  to  an  increase  in  milk  production,  but  merely  cause  the 
nursing  woman  to  put  on  useless  fat.  Such  excesses  are  not  only  useless 
but  should  be  especially  avoided  in  women  who  tend  to  corpulency  and  to 
insufficient  physical  exercise. 

After  lactation  has  been  fully  established,  hunger  is  similarly  without 
immediate  effect  upon  the  quality  and  quantity  of  the  milk.  Only  after 
a  long  sustained  and  severe  degree  of  starvation,  when  the  bodily  strength 
itself  wanes  and  emaciation  ensues,  is  a  decrease  in  the  quantity  and  proba- 
bly, also,  unfavorable  changes  in  the  quality  of  the  secretion  to  be  noted. 

The  fluid  requirement  of  the  mother  is  naturally  increased  during 
nursing.  This  may  be  met  by  drinking  large  quantities  of  water,  if  the  food 
contains  sufficient  nutriment.  The  use  of  large  quantities  of  rich  soup  has 
no  more  effect  upon  the  volume  of  the  secretion  than  has  alcohol  in  the 
form  of  beer  or  wine.  Nothing  can  be  said  against  the  use  of  beer  or  wine  in 
temperate  quantity.  Traces  of  alcohol  are  to  be  found  in  the  milk  only 
when  it  is  taken  in  very  large  amount. 

The  general  hygiene  of  the  nursing  woman  should  be  the  best  that  her 
environment  will  permit.  The  drawing  pains  in  the  back  which  so  com- 
monly occur  when  the  child  is  put  to  the  breast  may  be  relieved  in  many 
cases  by  supporting  a  pendulous  abdomen  or  by  taking  a  comfortable 
position  while  nursing  the  infant. 

The  breast,  and  especially  the  nipples,  should  be  kept  clean  by  fre- 
quent washing,  for  esthetic  if  not  for  hygienic  reasons,  even  though  the 
rough  surface  of  the  mammilla  cannot  be  completely  disinfected  by  ordi- 
nary measures. 

Of  the  medicinal  agents  which  it  may  be  necessary  to  give  internally 
to  the  nursing  mother,  only  iodine,  bromine  and  salicylic  acid  are  excreted 
in  the  milk  and  these  in  absolutely  harmless  quantities.  In  animals,  opium, 
morphine  and  atropine  also  pass  through.  Mercury,  in  event  that  the 
mother  is  treated  by  inunction,  is  excreted  in  the  milk,  but  in  such  minute 
quantities  that  it  is  impossible  to  expect  therapeutic  results  from  it  in  the 
child.  It  may  also  be  said  that  chloroform  anesthesia  in  the  mother  is 
entirely  without  importance  to  the  nursing  babe. 

After  the  confinement  the  menses  do  not  appear  at  all,  or  only  once 
some  five  to  six  weeks  after,  and  then  remain  absent  for  months  or  until 
the  end  of  lactation.  Occasionally,  they  appear  regularly  during  the  entire 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT         43 

period  of  nursing.  The  occurrence  of  the  menses  has  in  itself  no  influence 
upon  the  quantity  or  quality  of  the  milk,  nor  does  it  cause  restlessness  or 
digestive  disturbances  in  the  child.  When  the  breast  is  functionating 
indifferently  and  the  mother  is  much  affected  by  the  menstruation,  an 
increased  difficulty  in  emptying  the  breast  may  be  experienced,  together 
with  an  increased  nervous  irritability.  This  should  never  be  considered 
cause  for  additional  feeding. 

To  a  certain  extent  pregnancy  is  more  infrequent  in  nursing  women 
than  in  others  and  doubtless  the  women  who  are  amenorrhceic  during  the 
lactation  period  2  do  not  conceive  as  readily  as  those  who  menstruate 
regularly.  Neither  the  maintenance  of  lactation  nor  amenorrhcea  give 
absolute  assurance  that  conception  may  not  occur  during  their  course, 
but  it  is  very  probable  that  immunity  from  conception  is  present  for  several 
months  of  lactation  and  in  nursing  women  a  dangerously  rapid  sequence 
of  conceptions  is  not  seen  as  commonly  as  in  those  who  do  not  nurse  their 
children.  The  claim  of  some  mothers  that  they  have  had  to  wean  a  nursing 
child  because  of  a  new  pregnancy  is  often  due  to  the  error  of  regarding 
the  absence  of  the  menses  as  an  indication  of  conception.  Immediately 
upon  weaning  the  infant,  they  conceive  at  the  next  ovulation.  Other 
women,  on  the  contrary,  discover  a  pregnancy  only  after  several  months 
have  passed,  without  either  mother,  nursing  child  or  fetus  suffering  any 
harm  from  the  continued  lactation.  This  proves  that  pregnancy  of  several 
months'  duration  does  not  necessarily  cause  the  secretion  to  dry  up.  The 
child,  therefore,  should  never  be  weaned  suddenly  though  pregnancy  is 
suspected  and  even  when  it  is  definitely  determined,  the  weaning  should 
occur  gradually. 

All  these  facts  tend  to  show  that  obstacles  to  nursing  or  legitimate 
causes  for  its  interruption  occur  much  less  frequently  than  has  been  sup- 
posed both  by  the  laity  and  the  profession.  The  knowledge  of  this  and  the 
avoidance  of  those  numerous  rules  and  limitations  with  which  the  nursing 
mother  has  been  unreasonably  surrounded,  have  produced  a  gratifying 
increase  in  the  number  of  mothers  among  the  educated  classes  who  are 
willing  to  nurse  their  children.  It  is  knowledge,  however,  that  must  be 
brought  home  to  all  classes  of  people  by  the  physician,  and  its  spread  will  add 
greatly  toward  making  mothers  more  ready  and  more  able  to  nurse.  Then, 
too,  those  social  conditions  which  force  the  mother  to  seek  employment 
will  no  longer  necessarily  rob  the  child  of  the  food  provided  for  it  by  nature. 
The  value  of  this  to  the  individual  and  to  the  nation  is  to  be  considered. 
(See  Section  IV.) 

THE  TECHNIC  OF  BREAST  FEEDING. 

The  new-born  should  be  put  to  the  breast  of  the  mother  only  after  24 
hours.  If  the  child  seems  hungry  before  this  time  has  elapsed,  it  may  be 
given,  from  a  spoon,  a  little  water  sweetened  with  benzosulphinidum 
(saccharin).  If  the  infant  sleeps  for  a  still  longer  time,  the  sleep  should  not 

1  This  physiologic  amenorrhoea  depends  upon  a  more  complete  puerperal  involution 
of  the  reproductive  organs,  in  consequence  of  which  ovulation  is  arrested. 


44  TEXT-BOOK  OF  PEDIATRICS 

be  interrupted.    Quite  a  few  children  require  no  nourishment  for  36  to  48 
hours  after  birth. 

Infants  act  differently  in  their  first  attempts  at  nursing.  Some  im- 
mediately suckle  well  and  with  much  force ;  others  will  not  take  the  nipple 
or  let  go  after  a  few  attempts.  Nothing  is  to  be  gained  by  force.  The  child 
is  to  be  put  back  into  its  crib  and  the  attempt  repeated  after  an  interval. 
With  patience  and  continued  application  to  the  breast  every  normal  child 
will  learn  to  nurse.  If  the  breast  is  very  tense  and  difficult  to  empty  it  may 


FIG.  6. — Method  of  holding  baby  during  nursing. 

be  made  more  responsive  to  the  effort  of  the  child  by  expressing  or  pumping 
off  small  quantities  of  milk. 

Emphasis  should  be  put  upon  the  fact,  from  the  very  first,  that  the 
child  must  take  not  the  nipple  only,  but  also  almost  the  entire  areola  into  its 
mouth;  for  the  greater  the  portion  of  the  breast  included,  the  greater  is  the 
area  affected  by  the  stimulus  of  suckling  and  the  greater  is  the  reflex 
response.  This  practice  is  also  less  liable  to  tear  the  nipple  and  to  pro- 
duce fissures. 

The  nipple  shields  or  protectors,  consisting  of  a  glass  to  cover  the 
mammilla  and  a  rubber  nipple  for  the  child  to  suckle,  which  are  in  common 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT 


45 


use  and  are  intended  to  make  the  first  application  of  the  infant  to  the  breast 
easier,  or  are  used  out  of  an  excessive  fear  of  mastitis,  are  dangerous.  Their 
harmfulness  lies  in  the  fact  that  while  they  may  make  the  work  of  suckling 
easier  for  the  child,  the  unphysiologic  stimulus  makes  the  emptying  of  the 
breast  much  more  difficult.  The  continued  use  of  such  an  apparatus  almost 
always  leads  to  the  drying  up  of  the  secretion  and  the  under-nourishment  of 
the  child. 

Conical  breasts  are  more  easily  emptied  by  milking  movements  which 
make  slight  rhythmic  pressure  upon  the  areola;  flat  breasts  are  best 
emptied  by  pumping  apparatus.  Of  pumping  devices  there  are  numerous 
types.  The  teterelle  biaspiratrice,  which  was  formerly  in  common  use, 
consists  of  a  glass  bell  placed  over  the  nipple  and  supplied  with  two  pieces 
of  tubing,  from  the  one  of  which  the  mother  draws  the  air,  while  from  the 
other  the  child  takes  the  milk.  In  this  form, 
the  saliva  of  the  mother  easily  flows  into  the 
apparatus,  which  does  not  seem  to  be  very 
desirable.  Of  the  various  models  in  which 
a  negative  pressure  is  produced  by  a  rubber 
bulb,  the  pattern  designed  by  Ibrahim 
(Fig.  7)  is  easily  handled  and  readily 
cleaned.  With  rhythmic  compression  and 
release  of  the  heavy  walled  bulb,  the  action 
of  the  normal  suckling  apparatus  may  be 
imitated  to  some  extent;  but  here  also  the 
rhythmic  massage  of  the  areola  is  lacking 
and  the  breast  is  never  emptied  as  com- 
pletely as  by  the  suckling  of  a  strong  child. 

It  is  not  only  necessary  to  empty  the 
breast  completely  in  order  to  obtain  suffi- 
cient milk  for  the  child,  but  also  because 
this  is  the  only  method  which  stimulates  and  increases  the  initial  secretion 
and  prevents  congestion.  If  the  breast  is  not  completely  emptied,  the  irre- 
parable result,  an  unavoidable  one  during  the  first  few  weeks  and  often 
within  a  few  days,  is  the  complete  failure  of  the  secretion. 

The  colostrum  secreted  during  the  first  few  days  is  very  small  in  quantity 
and  often  measures  only  a  few  cubic  centimeters.  Usually,  after  the  third 
or  fourth  day,  but  often  not  until  the  fifth  or  sixth,  a  rapid  increase  of  the 
secretion  ensues,  which  in  many  women  is  accompanied  by  the  subjective 
feeling  of  the  "  shooting-in  "  of  the  milk.  At  the  same  time,  the  number  of 
colostrum  corpuscles  rapidly  sinks  to  a  minimum. 

The  further  increase  of  the  quantity  of  the  milk  is  dependent  on  the  one 
hand,  upon  the  amount  of  glandular  tissue  in  the  breast  and,  on  the  other 
hand,  upon  the  demand  made  upon  it.  These  two  factors  determine  the 
total  production  of  the  secretion,  as  well  as  the  time  at  which  the  function  is 
fully  established. 

The  question  whether  the  child  should  be  put  to  one  or  both  breasts  at 
each  feeding  can  be  answered  only  in  a  general  way  by  saying  that  the 


Fio.  7. — Breast  pump  (Ibrahim) 


46  TEXT-BOOK  OF  PEDIATRICS 

object  of  the  nursing  should  be  to  empty  the  breasts  as  completely  as 
possible  and  that  congestion  must  be  avoided.  Other  things  being  equal,  this 
occurs  to  a  greater  extent  in  small  breasts  than  in  large  ones.  It  is  per- 
missible at  times,  therefore,  to  apply  the  child  to  both  breasts  after  an  inter- 
val of  at  least  three  hours,  taking  care  only  that  the  child  receives  the 
second  breast  after  it  has  emptied  the  first  one  sufficiently.  By  beginning 
alternately  with  the  breast  from  which  the  child  has  nursed  last,  all  these 
demands  are  fulfilled  in  the  best  manner.  It  is  only  with  very  well 
developed  breasts  that  we  may  persist  in  giving  only  one  breast  from 
the  beginning. 

The  ease  with  which  the  breast  may  be  emptied,  whether  artificially  or 
by  the  nursing  infant,  varies  greatly  in  individuals  in  whom  the  quantity 
of  secretion  may  be  the  same.  It  often  happens  that  while  the  child  is 
nursing  from  one  breast,  the  milk  drops  or  even  spurts  from  the  other.3  The 
number  of  feedings  which  the  healthy  infant  will  take  spontaneously  from  a 
freely  secreting  breast  varies  between  five  and  six  in  24  hours;  but  it  may 
occasionally  fall  to  four  or  be  increased  to  seven.  It  is  recommended  and  is 
generally  accepted,  to-day,  that  three-hour  intervals  should  be  allowed  be- 
tween the  feedings  during  the  day  and  that  during  the  night  two  longer  in- 
tervals are  most  satisfactory  to  the  favorable  development  of  the  child. 

A  large  experience  with  new-born  and  older  infants  has  shown,  and  the 
method  has  been  generally  adopted  by  numerous  pediatrists,  that  an 
interval  of  four  hours  is  even  more  satisfactory.  This  is  true  both  from  the 
standpoint  of  the  child  and  of  the  mother.  The  editors  have  used  the  four- 
hour  feeding  for  a  number  of  years.  The  schedule  is  placed  in  force  24  to 
48  hours  after  birth.  On  the  part  of  the  child,  less  digestive  disturbances  are 
encountered  and  on  the  part  of  the  mother,  the  great  advantage  lies  in  the 
fact  that  she  is  given  more  freedom  for  work  or  social  duties.  Even  pre- 
matures are  more  successfully  fed  on  this  schedule.  The  hours  for  nursing 
most  frequently  recommended  are  6  A.  M.;  10  A.  M.;  2  P.  M.;  6  P.  M.;  10  p.  M. 
and  one  night  feeding  at  2  A.  M.,  if  necessary. 

It  is  usually  superfluous  to  prescribe  the  length  of  the  individual  period 
of  nursing  for  the  healthy  infant,  .because  when  satisfied  it  stops  suckling, 
often  falling  asleep  at  the  breast.  Some  children  suckle  for  a  moment  and 
then  stop,  and  when  the  attempt  is  made  to  remove  them  from  the  breast 
grasp  it  greedily,  to  suckle  again  for  a  moment.  In  such  children  the  time 
of  nursing  should  be  limited  to  fifteen  or  twenty  minutes  at  the  most. 

It  may  be  shown,  by  weighing  the  child  at  equal  intervals  of  about 
five  minutes,  that  the  quantities  taken  during  successive  periods  of  nursing 
decrease  very  rapidly  and  that  only  a  few  grams  are  taken  after  the  first 

3  After  long  intervals  between  nursings,  and  especially  at  night,  is  this  apt  to  occur. 
In  many  women,  some  milk  flows  from  the  breast  after  long  intervals  in  nursing  and 
more  especially  after  the  night  interval.  This  becomes  annoying  and  disturbing  only 
when  it  occurs  immediately  after  putting  the  child  to  the  breast  and  when  because  of  an  ab- 
normally low  tone  of  the  sphincter  mammillae,  a  sort  of  incontinence  or  galactorrhea  results. 
Obstinate  eczema  of  the  areola  and  of  the  skin  over  the  breast  may  ensue.  The  treatment 
of  this  anomaly,  which  usually  appears  to  be  of  neuropathic  origin,  is  generally  quite  use- 
less and  must  confine  itself  to  the  application  of  dressings  to  absorb  the  milk  and  to  the 
treatment  of  the  eczema  with  ichthyol  or  with  silver  nitrate  solution  (2-3  per  cent). 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT         47 

twenty  minutes.  The  long-drawn-out  nursing  period  not  only  wastes  the 
mother's  time  and  strength  but  is  actually  dangerous  because  of  the 
maceration  of  the  nipple  and  the  consequent  liability  to  fissures. 

The  quantity  of  milk  taken  at  each  nursing,  determined  by  weighing  the 
child  before  and  after  putting  it  to  the  breast,  varies  within  wide  limits. 
Usually  the  secretion  is  most  abundant  at  the  first  morning  feeding  and  is 
often  two  to  three  times  as  great  as  that  of  the  smallest  output  which  is 
usually  had  late  in  the  afternoon.  This  is  most  definitely  observed  after  an 
interval  of  the  whole  night  especially  in  breasts  of  large  capacity. 

The  total  quantity  of  the  twenty-hour  hours'  secretion  is  of  greater 
import  to  the  physician.  It  will  be  seen  from  the  above  statement  that 
this  total  can  never  be  obtained  by  multiplying  the  amount  secured  at  one 
nursing  by  the  number  of  feedings,  but  must  be  determined  by  weighing  the 
child  before  and  after  each  nursing.  The  quantity  of  milk  which  the  infant 
receives  within  the  24  hours  varies  also  from  day  to  day;  the  variance 
running  at  times  from  200-300  c.c.,  so  that  the  knowledge  of  the  quantity  of 
any  one  day's  feeding  permits  only  indefinite  conclusions  upon  the  total 
amounts  regularly  taken.  On  this  account,  Czerny  and  Keller  have 
adopted  as  a  standard  the  average  of  the  total  output  of  five  days.  Except- 
ing from  this  estimate  the  first  8  or  10  days,  when  great  irregularities  occur, 
it  has  been  determined  that  the  amount  of  nourishment  taken  during  the 
first  few  weeks  equals  about  one-fifth  of  the  body-weight.  This  quantity  is 
gradually  reduced  to  about  one-sixth  or  one-seventh,  between  the  first  to  the 
fourth  month,  and  at  the  end  of  the  first  six  months  it  equals  about  one- 
eighth  of  the  body-weight.  This  gradual  reduction  of  the  relative  quantities 
of  food  stands  in  close  relation  to  the  conditions  described  on  page  22. 
When  the  quantities  of  food  taken  and  the  body-weight  are  represented  by 
curves  a  marked  divergence  appears,  in  that  the  weight  curve  continually 
rises  while  the  food  curve,  representing  food  quantities,  becomes  more  and 
more  flattened.  It  must  be  said,  however,  that  cases  have  been  observed  in 
which  the  two  curves  ran  parallel  for  months. 

Under  normal  circumstances  both  breasts  commonly  secrete  like  quanti- 
ties, but  it  is  not  exceptional  to  find  women  in  whom  one  breast  secretes 
more  freely  than  the  other  throughout  lactation.  Similarly,  women  are 
quite  often  found  in  whom  one  breast  has  been  depreciated  by  a  former 
mastitis,  but  are  able,  for  many  months,  to  produce  sufficient  milk  with  the 
remaining  gland  which  has  become  structurally  and  functionally  hyper- 
trophied.  This  is  especially  interesting  when  there  are  twins,  in  which  case 
each  child  usually  suckles  one  breast. 

When  the  quantities  of  food  fall  markedly  below  the  average  given  and 
still  produce  satisfactory  increases  in  weight,  we  are  justified  in  the  suppo- 
sition that  this  depends  upon  a  higher  fat-content  of  the  particular  secretion. 
This  has  been  proved  in  a  case  reported  by  Heubner.  The  occurrence  of 
such  individual  differences,  uninfluenced  by  the  mode  of  life  of  the  nursing 
mother,  has  been  established  by  careful  observations  made  under  due  pre- 
cautions. It  would  seem,  generally  speaking,  that  the  fat-content  of  milk 
from  breasts  giving  small  total  quantities  is  relatively  much  greater  than  in 


48 


TEXT-BOOK  OF  PEDIATRICS 


breasts  which  secrete  greatly  in  excess  of  the  quantities  required  by  any 
one  child.  Wet-nurses,  for  instance,  are  found  in  institutions,  who  give 
two  to  three  litres  per  day  of  such  milk.  When  several  children  are  put 
to  the  same  breast  in  succession,  the  first  child  to  nurse  receives  milk 
containing  the  lowest  percentage  of  fat. 

The  weight  increase  is  looked  upon  as  the  chief  index  to  the  results  of 
feeding.  This  view  is  probably  justified  by  the  large  consideration  to  be 
given  to  the  congenital  tendency  to  growth  and  the  many-sided  import  of 


FIG.  8. 

weight  increase,  but  it  should  not  be  permitted  to  overshadow  such  other 
signs  of  general  well-being  in  the  child  as  its  color,  turgor,  disposition  and 
sleep,  the  development  of  its  static  functions  and  its  reaction  to  infections. 
The  normal  condition  of  the  child  in  all  these  respects  is  more  important 
than  the  rapid  increase  of  weight. 

In  healthy  children  who  develop  well,  the  weekly  increase  varies  in  the 
second  and  third  quarters  of  the  first  year  between  150  and  250  grams  and 
occasionally  even  300  grams;  and  in  such  a  regulated  manner  that  especially 
large  increases  of  one  week  will  be  equalized  by  smaller  increases  in  the  next, 
and  vice  versa. 

If  the  increase  in  weight  remains  for  a  considerable  period  below  what 
would  naturally  be  expected,  the  cause  should  not  be  laid  unconditionally 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT         49 

to  underfeeding.  We  should  rather  seek  to  determine,  by  the  methods 
already  cited,  whether  the  quantity  of  food  is  actually  too  small  and  if  so 
whether  the  fault  lies  in  a  positive  lack  of  milk,  in  a  weakness  of  suckling, 
or  in  anorexia  hi  the  child  due,  for  instance,  to  parenteral  infection.  The 
last  of  these  alternatives  is  much  more  common  than  is  generally  believed. 
To  avoid  serious  errors,  every  other  cause  of  disturbance  upon  the  part  of 
the  child  should  be  certainly  excluded  before  means  are  taken  to  increase  the 
food  artificially. 

As  we  have  already  said,  the  time  of  the  "coming  in"  of  the  milk  and 
the  rapidity  of  its  increase  in  quantity — stimulated  by  the  suckling  of  the 
child  and  by  the  measure  of  its  food  requirement — varies  greatly  in  dif- 
ferent individuals  and  is  usually  slower  in  primiparse  than  after  repeated 
lactations.  This  possibility  and  the  axiomatic  fact  that  even  scant  nour- 
ishment at  the  breast  for  a  certain  period  does  not  injure  the  child,  justifies 
the  physician  in  keeping  the  patient  under  careful  observation  and  waiting, 
as  long  as  possible,  for  the  full  establishment  of  lactation  in  these  cases  of 
delayed  beginning,  or  slowly  increasing  output.  As  a  guide,  it  may  be 
stated  that  after  the  physiologic  loss  of  weight  has  occurred  (see  page  24), 
a  lesser  loss  of  5  to  10  grams  a  day  may  occur  and  that  such  loss  may  be 
permitted  to  continue  for  one  or  two  weeks,  giving  the  child  only  a  little 
water  sweetened  with  benzosulphinidum  (saccharin).  If  no  increase  in 
milk  secretion  or  in  the  body-weight  of  the  child  occurs  by  this  time, 
it  becomes  necessary  to  supplement  the  insufficient  breast-feeding  and  us- 
ually with  some  artificial  mixture. 

It  may  be  possible,  in  rare  cases,  to  give  the  child  who  does  not  receive 
sufficient  milk  from  its  mother,  several  adequate  feedings  a  day  at  the 
breast  of  a  wet-nurse.  It  may  be  stated  emphatically,  that  in  case  of 
necessity,  the  child  may  receive  each  feeding  from  a  different  wet-nurse, 
as  has  been  done  in  certain  institutions,  and  it  may  still  develop  ex- 
ceptionally well. 

The  addition  of  artificial  food  to  the  breast  feeding,  a  method  to  which 
the  French  term  allaitement  mixte,  or  mixed  feeding,  has  been  applied, 
serves  much  more  favorably  for  the  development  of  the  child  than  arti- 
ficial feeding  alone,  and  it  should  be  recommended  more  frequently  by 
physicians  than  it  is.  Since  the  once  deep-rooted  prejudice  against  this 
mixed  feeding,  or  the  alternation  of  natural  and  artificial  food,  has  proven 
entirely  without  foundation,  the  lack  of  sufficient  secretion  by  the  mother 's 
breast  should  never  be  an  occasion  for  weaning,  but  always  an  indication  for 
the  addition  of  other  food.  In  such  cases,  it  may  be  well  to  give  the  bottle 
once  or  twice  daily,  or  later,  at  the  most,  three  tunes  during  the  24  hours,  in 
place  of  the  breast;  or  instead  of  this  to  the  scanty  breast  feeding,  the 
artificial  food  may  be  immediately  added  once,  or  several  times,  a  day  in 
sufficient  quantity  to  satisfy  the  infant. 

Each  of  these  two  methods  has  been  successfully  used  and  has  been 
recommended ;  either  is  justified  in  suitable  cases.  It  is  of  prime  importance, 
whichever  method  is  followed,  to  prevent  the  child  from  being  weaned. 
Further,  preference  may  be  lent  to  the  easier  way  of  giving  the  added  nour- 


60  TEXT-BOOK  OF  PEDIATRICS 

ishment.  The  surest  avoidance  of  weaning  is  found  in  the  first  form  of 
mixed  feeding,  that  is,  by  the  alternate  feeding  at  the  breast  and  from  the 
bottle.  This  type  of  mixed  feeding  is,  too,  the  only  possible  one  when  the 
mother  is  hindered  by  outside  demands  from  nursing  the  infant  regularly. 
Either  method,  however,  should  be  carried  out  under  strict  observation, 


FIG.  9. 

giving  the  child  only  such  quantity  of  artificial  food  as  is  absolutely 
required,  so  that  it  will  continue  to  empty  the  breast  completely  and  so 
prevent  congestion  and  the  arrest  of  the  secretion.  Otherwise  a  result, 
frequently  seen  in  practice,  soon  obtains  in  the  infant 's  refusal  to  nurse  the 
scantily  secreting  breast,  thus  "weaning  itself,"  because  "it  does  not  care 
for  the  breast  any  more."  The  choice  of  the  food  to  be  used  in  mixed 
feeding  depends  upon  the  accepted  standards  of  artificial  supply. 

If  the  occasion  for  mixed  feeding  disappears,  it  may  be  possible  to  dis- 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT         51 

continue  it  in  favor  of  exclusive  breast  feeding.  Thus,  with  an  initially 
scanty  secretion,  the  continued  strong  suckling  of  the  infant  may  stimulate 
the  breast  to  the  point  of  sufficiency;  or,  in  event  of  hitherto  enforced 
absence,  it  may  become  no  longer  necessary  for  the  mother  to  be  away  from 
the  child  for  hours  at  a  time.  Since  the  secretory  capacity  of  the  mammary 
gland  is  dependent  within  wide  limits  upon  the  demands  made  upon  it,  the 
quantity  of  the  secretion  usually  becomes  sufficient  in  amount  within  a  few 
days  after  the  abandonment  of  mixed  feeding.  It  is  even  possible  to  bring 
a  breast  which  has  almost  entirely  dried  up  back  to  full  function  again.  This 
so-called  re-lactation,  however,  occurs  only  when  the  colostrum  formation 
has  not  advanced  too  far. 

WEANING 

In  spite  of  the  fact  that  the  period  of  lactation  itself,  as  already  said,  is 
almost  unlimited  and  that  the  secretion  itself  may  be  adequate  to  produce 
satisfactory  and  normal  gains  in  weight  even  beyond  the  first  year,  it  is 
neither  customary  nor  advisable  to  continue  breast  feeding  exclusively  for 
so  long  a  time.  In  the  first  place,  the  normally  developed  breast-fed  child 
will  indicate  its  desire  for  other  food  much  earlier;  often,  at  about  the  sixth 
or  eighth  month  taking  bread  and  the  like  in  its  mouth  and  eating  it.  In 
the  second  place,  the  additional  food  given  at  this  time  acts  in  a  clearly 
favorable  manner,  maintaining  the  natural  fresh  color  and  sound  turgor, 
promoting  the  development  of  the  bones  and  the  exercise  of  static  functions. 

Whether  this  beneficial  action  of  the  additional  food  is  due  to  the  added 
carbohydrate  supply  or  to  the  increase  of  inorganic  salts,  particularly  cal- 
cium and  iron,  both  of  which  are  present  in  relatively  small  amounts  in 
human  milk,  is  beside  the  question.  It  is  certain  that  the  natural  transition 
to  the  mixed  dietary  of  adult  life  is  satisfactorily  made  in  this  manner. 

The  time  as  well  as  the  methods  of  the  transition  show  great  variation  in 
accord  with  the  customs  of  the  country  and  it  is  not  always  made  in  a 
proper  manner  The  error  of  too  early  feeding,  so  early  indeed  as  the  third 
or  fourth  month  with  large  quantities  of  sweet  or  starchy  foods  and  breads 
or  with  animal  milk,  is  much  more  common  than  the  error  of  too  long 
exclusive  feeding  with  breast-milk 

We  recommend  the  method  of  Czerny,  now  very  generally  accepted  by 
podiatrists,  of  beginning  at  the  sixth  or  seventh  month  to  substitute  for  the 
noon-meal  of  breast-milk  some  5  to  7  ounces  of  farinaceous  soup  prepared 
with  meat  broth.  The  soup-stock  should  be  prepared  from  a  quarter  of  a 
pound  of  meat  and  should  contain  the  same  condiments  (salt  and  vege- 
tables) as  may  be  used  for  adults,  but  the  fat  should  be  completely  skimmed 
off  and  it  should  not  contain  so  large  quantities  of  lime  salts  as  may  be  found 
in  broths  made  from  calves'  feet  or  young  fowls,  because  these  will  produce 
diarrhoea  in  some  children. 

After  several  weeks,  or  even  after  several  months,  if  perfectly  safe  milk 
cannot  be  obtained,  as  may  be  true  during  the  summer  months,  a  second 
breast  feeding  is  replaced  by  an  artificial  feeding  consisting  of  cow's  milk 
and  flour  soup,  or  milk  and  toast.  These  feedings  should  be  in  accord  in 


52  TEXT-BOOK  OF  PEDIATRICS 

quantity  with  those  recommended  for  a  child  of  given  age  and  weight. 
Gradually,  with  intervals  of  at  least  several  days,  the  remaining  breast 
feedings  are  replaced  in  a  similar  manner.  During  the  process,  however,  the 
breast  and  the  artificial  feedings  should  alternate,  in  order  to  prevent 
marked  congestion  of  the  milk  in  the  breast.  When  the  weaning  is  com- 
plete, the  child's  menu  may  be  varied  by  the  addition  of  any  one  of  the 
large  variety  of  soups  (rice,  sago,  potato,  legumens,  etc.),  or  of  one  or  two 
tablespoonfuls  of  mashed  vegetables  (carrots,  spinach,  cauliflower,  etc.), 
or  by  replacing  the  milk  and  flour  soup,  or  the  milk  and  toast  by  a  more 
nourishing  milk  pap,  made  with  cereals,  rice,  etc. 

Stewed  or  raw,  scraped  vegetables  should,  for  pedagogic  reasons,  be 
given  only  after  the  child  has  acquired  the  taste  for  several  of  the  mashed 
vegetables,  otherwise  it  may  be  difficult  to  teach  the  child  to  eat  the  latter. 
Even  with  the  greatest  variety  of  food,  care  should  be  taken  to  prevent  the 
child  from  being  " spoiled"  and  capriciously  selecting  its  own  food.  When 
vegetables  are  given,  it  is  well  to  warn  the  mother  to  expect  the  appearance 
of  undigested  shreds  in  the  stool,  for  if  this  is  not  done  she  may  become 
frightened  and  discontinue  their  use  in  the  belief  that  they  are  indigestible. 

Even  large  and  strong  children  should  not  be  given  more  than  one  quart 
of  milk  daily  at  the  end  of  the  first  year.  The  milk  other  than  contained  in 
gruels,  etc.,  should  not  be  fed  from  the  bottle.  It  is  better,  even  if  somewhat 
more  troublesome,  to  teach  the  child  to  take  the  food  from  a  cup  or  mug 
after  it  has  learned  to  take  soup  from  a  spoon,  because  this  is  the  natural 
mode  of  drinking. 

The  unpleasant  custom,  a  widespread  one  in  some  countries,  of  allowing 
children,  who  are  running  about  or  even  of  school  age,  to  take  their  milk 
from  a  bottle,  because  they  will  drink  more  by  this  means,  is  not  only  irra- 
tional and  unesthetic  but  is  a  practice  harmful,  as  all  long-continued  suck- 
ing is,  to  the  process  of  dentition. 

WET-NURSING 

The  only  perfect  substitute  4  for  mother's  milk  is  the  milk  of  a  wet-nurse. 
The  only  prerequisites  are  that  the  wet-nurse  be  healthy  and  that  she 
have  sufficient  milk.  The  qualitative  differences  that  may  obtain  in  the 
milk  of  different  women  play  no  part  in  the  nourishment  of  a  healthy 
infant.  As  an  actual  fact,  everything  that  has  been  reported  concerning 
the  unfitness  of  the  milk  of  certain  mothers  is  due  to  the  improper  inter- 
pretation of  superficial  observations. 

Even  though  difficulties  in  the  establishment  and  maintenance  of 
wet-nursing  are  very  frequently  encountered  in  private  practice,  these 
difficulties  almost  always  result  from  avoidable  errors  due  to  a  lack  of 

4  This  is  not  true  in  an  ethical  sense.  The  mother  who  does  not  nurse  her  child,  but 
leaves  its  feeding  and  care  to  the  wet-nurse,  has  later  great  difficulty  in  regaining  the 
tender  love  of  her  babe  which  naturally  turns  from  her  to  its  nurse.  She  risks,  further, 
the  danger  of  having  the  child  acquire  the  personal  characteristics  and  habits  of  the 
nurse,  which  are  often  far  from  desirable.  That  individual  peculiarities  may  be  trans- 
ferred with  the  milk  is  not  true,  although  it  was  formerly  believed.  Their  acquirement  is 
entirely  due  to  the  unconscious  mimicry  of  the  child. 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT         53 

knowledge  of  the  basic  principles  of  normal  lactation  or  of  the  physiology 
and  pathology  of  the  breast-fed  infant.  The  conditions  for  wet-nursing  are 
the  same  as  obtain  for  the  feeding  of  the  child  at  the  mother's  breast. 
The  frequent  change  of  wet-nurses  is,  therefore,  in  most  cases,  a  poor 
testimonial  to  the  knowledge  of  the  physician  in  charge. 

A  very  common  error  is  made  in  demanding  for  a  weak  infant  who  can 
take  but  small  quantities  of  food,  a  wet-nurse  who  has  a  large  supply  of 
milk,  a  condition  always  distinctly  specified  alike  by  physicians  and  parents. 
The  natural  results,  in  congestion  of  the  breast  and  in  decrease  and  final 
disappearance  of  the  secretion,  may  be  avoided,  often,  only  by  pumping  the 
excess  of  milk  or  by  permitting  the  wet-nurse 's  own  child,5  which  she  also 
nurses,  to  empty  the  breast  completely.  It  is  best,  however,  when  selecting 
a  wet-nurse  to  see  that  there  is  a  reasonable  relation  between  the  quantity 
of  milk  secreted  and  the  food  requirement  of  the  child. 

The  provision  of  wet-nurses  was,  up  to  a  few  years  ago,  a  very  serious 
matter  and  is  still  difficult  from  the  medical  as  well  as  the  sociologic  and 
ethical  viewpoint. 

Wet-nurses  recommended  and  introduced  by  employment  agencies,  by 
which  they  are  tempted  with  promises  of  well-paid  positions,  are  usually  in 
the  stage  of  well-developed  congestion  of  the  breasts  and  are  often  in  danger 
of  losing  their  milk  when  they  accept  a  position.  It  is  not  surprising,  under 
this  method  of  hiring  a  wet-nurse,  that  her  family  history  and  the  detail  of 
her  past  life,  previous  illnesses,  etc.,  most  certainly  necessary  to  establish 
her  fitness  as  a  wet-nurse,  are  usually  intentionally  falsified ;  while  the  child 
which  is  shown  to  the  physician  is  often  not  her  own,  a  fact  which  develops 
most  unexpectedly  and  unpleasantly  later  on. 

Her  physical  examination  should,  of  course,  be  very  complete  and  should 
be  directed  especially  to  the  discovery  of  tuberculosis,  syphilis,  gonorrhea, 
and  parasitic  and  infectious  skin  diseases.  In  view  of  the  frequency  with 
which  the  von  Pirquet  reaction  is  positive,  indicating  latent  tuberculous 
foci  in  the  adult,  it  is  not  a  sufficient  reason  for  rejecting  an  otherwise 
satisfactory  wet-nurse.  The  Wassermann  reaction  should  be  made  as  a 
matter  of  routine.  The  inspection  of  the  wet-nurse 's  child,  which  is  not 
always  possible,  is  much  less  certain  than  the  blood  examination  in  the 
exclusion  of  syphilis.  With  practice,  it  is  possible  to  determine  approx- 
imately by  palpation  of  the  breast,  which  is  not  intentionally  congested, 
whether  there  is  a  sufficient  output.  There  should  be  sufficient  tense  gland- 
ular tissue,  which  is  harder  than  the  surrounding  fat.  The  skin  over  the 
breast  is  warmer  than  over  the  sternum  and  has  numerous  large  veins 
passing  through  it.  Exact  knowledge  of  the  quantity  of  milk  may  be 
obtained  only  by  weighing  the  child  before  and  after  feeding. 

The  numerous  dangers  which  arise  in  hiring  a  wet-nurse  from  an 
employment  agency,  briefly  indicated  above,  may  be  avoided  if  the  wet- 
nurse  is  taken  from  an  institution,  an  infant  and  lying-in  hospital,  etc., 

8  This  method,  which  is  advisable  because  it  is  humane,  is  practicable  in  suffi- 
ciently well-to-do  families  and  should  be  considered  whenever  possible. 


54  TEXT-BOOK  OF  PEDIATRICS 

in  which  she  and  her  child  have  been  observed  6  by  unprejudiced  attendants, 
for  weeks  or  months,  as  to  their  health  and  general  characteristics  and  the 
adequacy  of  the  breast  yield.  They  have  usually  learned,  in  such  an  insti- 
tution, to  handle  and  to  properly  care  for  an  infant. 

The  old  rule  that  the  wet-nurse 's  infant  should  be  about  the  same  age  as 
the  child  that  she  is  to  nurse  is  now  believed  to  be  without  foundation.  It 
is  rather  desirable  for  the  reasons  cited  to  select  a  nurse  for  even  a  new-born 
infant,  whose  lactation  has  been  established  for  several  months.  If  we  can 
be  certain  that  the  lactation  is  well  established,  a  mother  who  is  nursing  for 
the  first  time  will  prove  entirely  satisfactory. 

Even  though  she  takes  care  of  the  child  and  helpswith  the  housework  and 
is  not  fed  with  too  great  luxury,  the  wet-nurse  tends  to  be  a  great  expense 
because  of  her  high  wages  and  the  necessity  that  a  room  be  provided  for  her. 

Mixed  feeding  (allaitement  mixte)  secured  by  the  employment  of  a 
wet-nurse  who  comes  to  the  home  to  nurse  the  infant  once  or  twice  a  day,  is 
much  cheaper  and  is  in  most  cases  a  satisfactory  substitute  for  the  exclu- 
sively used  wet-nurse.  Every  healthy  woman  who  has  sufficient  milk,  if 
she  wishes  to  nurse  the  child  several  times  a  day,  may  accomplish  this 
either  by  going  to  the  child  or  by  having  the  child  brought  to  her.  If  the 
child  is  given  the  breast  three  times  a  day,  it  will  be  necessary  to  give  two 
artificial  feedings  in  the  intervals.  When  the  nurse  comes  to  the  house  for 
nursing  periods  only  and  keeps  her  own  child,  also  partially  fed  at  the  breast, 
most  of  the  unpleasant  features  of  the  situation  arising  when  the  wet- 
nurse  must  be  taken  into  the  house  and  treated  as  a  companion  disappear. 
The  test  weighings  of  the  child,  before  and  after  nursing,  to  ascertain  the 
quantity  of  milk  obtained  from  the  nurse,  are  to  be  recommended  as  a 
matter  of  reassurance  to  the  parents  and  as  a  control  measure  when  the 
child  does  not  develop  as  well  as  might  be  expected.  In  this  method  of 
mixed  milk  feeding,  a  complete  knowledge  of  the  physiology  and  pathology 
of  infancy  is  as  necessary  as  it  is  in  all  other  forms  of  feeding.  It  is  especially 
important  for  the  physician  to  meet  the  many  superstitions  of  the  mother, 
who  will  see  a  dietetic  error  of  the  nurse  in  every  cry  and  in  every  irregu- 
larity of  the  stools  of  the  infant. 

6.  ARTIFICIAL  FEEDING 

Artificial  feeding,  surrounded  by  a  grim  troop  of  dangers,  stands  in 
distinct  contrast  to  the  certainty  with  which  normal  growth  and  develop- 
ment occur  at  the  mother's  breast.  This  is  proved  most  clearly  by  the 
high  mortality  rate  of  the  artificially-fed.  These  dangers  depend  partly 
upon  the  decomposition  of  the  component  parts  of  the  animal 's  milk  used 
in  making  the  artificial  food,  and  partly  upon  chemical  differences  between 
human  and  animal  milk  which  cannot  be  entirely  met.  These  dangers  are 
greater  the  earlier  the  artificial  feeding  is  begun. 

6  In  such  institutions  the  wet-nurse 's  child  will  find  a  home  and  be  cared  for,  which, 
in  part,  reduces  the  expense.  A  law  regulating  wet-nurses,  with  special  regard  for  the 
wet-nurse 's  child,  has  been  rightfully  demanded  from  various  sources. 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT         55 

MILK  FOR  INFANTS 

The  first  of  these  difficulties  of  artificial  feeding  may  be  measurably 
reduced  if  the  most  scrupulous  care  is  exercised  in  the  dairying  and  handling 
of  the  milk.  Milk  so  secured  and  treated  is  usually  marketed  under  some 
distinctive  name  as  "milk  for  infants,"  certified,  sanitary,  or  inspected 
milk.  Under  insufficient  legal  regulation,  no  name  in  itself  offers  any  assur- 
ance of  the  purity  of  the  milk,  unless  it  stands  for  actual  inspection  and 
certification.  On  the  other  hand,  milk  not  sold  under  label,  is  not  necessarily 
contaminated  and  unfit  for  infant  feeding. 

Aside  from  intentional  contamination,  punishable  by  law,  such  as 
partial  skimming  or  the  addition  of  water  or  preservatives,  to  hide  already 
advanced  souring,  and  aside  from  the  accidental  admixture  of  pathogenic 
organisms,  the  chief  source  of  the  impurities  of  milk  lies  in  the  implantation 
of  greater  or  less  numbers  of  saprophytes  which,  with  varying  rapidity, 
induce  its  complete  decomposition. 

The  larger  number  of  these  organisms  come  from  the  impurities  which 
fall  into  the  milk  during  the  process  of  milking,  and  consist  of  hairs, 
epidermal  scales,  manure,  particles  of  food  and  stable  dirt.  These  im- 
purities are  carried  into  the  milk  by  air  currents,  or  from  the  hands  of  the 
milker,  or  from  dirty  vessels  and  implements,  or  by  dirty  water  with  which 
the  latter  are  rinsed. 

Therefore,  the  extreme  cleanliness  of  the  cow  and  especially  of  the  cow's 
udder  is  important.  Care  should  be  taken  not  to  stir  up  dust  in  the  stable 
from  bedding  or  foddering  shortly  before  milking  and  the  greatest  possible 
cleanliness  of  the  entire  equipment,  not  only  of  the  hands  and  clothes  of  the 
milkers  but  also  of  the  vessels  used  in  milking  and  in  gathering  and  measuring 
the  milk,  of  the  straining  cloths,  etc.,  should  be  secured.  In  other  words, 
asepsis,  as  complete  as  possible,  should  be  practiced  in  obtaining  the  milk  to 
be  used  for  infant  feeding.  Further  bacterial  contamination  occurring  in 
the  handling  and  transporting  of  milk,  in  pouring  it  into  different  containers 
and  in  measuring  it  for  sale,  is  relatively  small.  The  primary  contamination 
which  the  milk  receives  in  the  dairy  increases  steadily  and  extensively,  in 
proportion  to  the  degree  of  its  first  infection,  to  the  length  of  time  during 
which  it  is  kept  at  body  temperature  and  to  the  period  of  tune  consumed  in 
carrying  it  from  the  dairy  to  the  consumer. 

Thus  it  will  be  seen  that  the  proper  care  of  milk  demands  the  greatest 
precautions  in  milking,  in  immediate  chilling,  and  in  rapid  delivery  to  the 
consumer.  After  it  has  reached  the  home,  the  responsibility  of  its  keeping 
rests  with  the  housekeeper. 

It  is  self-evident  that  the  milk  of  diseased  animals  should  not  be  used 
for  infants.  The  question  whether  the  milk  of  cattle  which  give  a  positive 
reaction  to  tuberculin,  but  present  no  clinical  evidence  of  tuberculosis  and, 
especially,  no  sign  of  tuberculosis  of  the  udder,  is  unsafe  and  one  most  diffi- 
cult to  decide  and  is  still  under  discussion.  There  is  no  doubt,  however,  that 
strict  adherence  to  this  rule  will  increase  the  price  of  milk  very  materially. 
In  the  better  dairies,  which  furnish  special  milk  for  infants,  it  has  been  found 
sufficient  to  have  the  dry  udder  frequently  and  carefully  examined,  say  at 


56  TEXT-BOOK  OF  PEDIATRICS 

least  once  a  month  by  a  veterinarian,  thus  insuring  the  timely  discovery  of 
tubercles,  as  well  as  of  the  streptococcus  infection  or  mastitis. 

Green  fodder  and  silage  have  to  a  great  extent  replaced  dry  fodder  in  the 
diets  of  dairy  cattle.  Such  feedings  must  be  regulated  so  as  not  to  cause 
diarrhoea  which  increases  the  difficulty  of  obtaining  sanitary  milk  on 
account  of  the  soiling  of  the  udder  and  the  probable  introduction  of  enor- 
mous numbers  of  acid-forming  bacteria  into  the  milk. 

Where  there  are  local  dairies  or  institutions  marketing  milk  for  infant 
use  which  are  well  equipped  and  carefully  managed,  the  milk  should,  of 
course,  be  procured  from  them.  But  the  necessity  of  transporting  milk  a 
long  distance  by  rail  or  wagon  in  the  summer,  may  make  the  advantages  of 
sanitary  milking  and  immediate  cooling  somewhat  illusive;  so  that  it  is 
usually  better  to  purchase  milk  from  a  near-by  source,  which  may  not  have 
been  obtained  under  as  sanitary  circumstances,  or  even  to  secure  it  fresh 
from  the  cow  several  times  a  day  and  to  use  it  immediately. 

Where  neither  the  one  nor  the  other  method  of  obtaining  pure  cow's 
milk  is  practical,  all  the  difficulties  may  be  surmounted  by  keeping  a  goat. 
Goat's  milk  is  as  satisfactory  as  cow's  milk  for  infant  feeding.  Besides, 
tuberculosis  is  very  rare  among  goats;  the  animal  is  more  easily  kept  clean 
and  the  milk  is  more  readily  obtained  in  a  sanitary  state. 

A  far-reaching  control  of  milk  is  possible  under  a  system  of  municipal 
inspection.  Such  control  concerns  itself  not  only  with  examination  of  the 
milk  as  to  its  dilution,  skimming,  etc.,  but  it  also  determines  the  presence  of 
dirt,  the  number  of  leucocytes  (Trommsdorf  test)  and  of  micro-organisms, 
and  the  degree  of  acidity,  according  to  the  method  of  Soxhlet-Henkel.7 
Since  the  housekeeper  has  to  depend  upon  the  very  indefinite  tests  of 
appearance,  taste  and  smell,  or  finally,  upon  an  experimental  boiling,  the 
knowledge  of  the  source  and  freshness  of  milk  is  all  the  more  important 
to  her. 

The  Pasteurization  of  milk  in  bulk,  which  has  been  advised  so  frequently 
and  is  quite  practical,  cannot  be  recommended  for  milk  intended  for  infant 
feeding.  In  the  ordinary  milk  purchased  in  the  open  market,  which  is  often 
consumed  without  being  boiled,  Pasteurization  guarantees  the  destruction 
of  pathogenic  organisms;  but  in  milk  for  infant  use,  which  is  always  boiled 
before  being  used,  it  hides  the  important  indications  of  age  and  insufficient 
cleanliness  by  destroying  the  relatively  harmless  acid-forming  bacteria 
while  the  much  more  dangerous  spore-forming  peptonizing  bacteria 
(Fliigge)  remain  active.  Moreover,  as  the  possibility  of  subsequent  con- 
tamination makes  the  reheating  of  the  milk  in  the  home  necessary,  it  is 
certainly  not  a  particularly  advantageous  thing. 

7  One  degree  of  acidity  is  the  amount  of  acidity  in  50  c.c.  of  milk  which  will  be 

N 
neutralized  by  1  c.C.  -j  sodium  hydroxide.     Phenolphthalein   is  used  as  an  indicator. 

Fresh  milk  has  2-4  degrees  of  acidity  and  remains  at  this  stage  (incubation)  for  from 
3-8  hours  at  body  temperature;  or  at  10°  C.  for  52-72  hours,  depending  upon  the  degree 
of  cleanliness  in  milking.  Milk  curdles  upon  boiling  when  it  has  5.5-6.5  degrees  of 
acidity.  Spontaneous  curdling  occurs  in  milk  of  15-16  degrees  of  acidity.  Thus  we  are 
able  to  determine  age  and  composition  approximately  by  titration.  (Plaut;  quoted  from 
Finkelstein's  Text-book.) 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT         57 

The  question,  actively  discussed  for  years,  whether  the  injuries  con- 
nected with  artificial  feeding  may  not  be  more  or  less  avoided  by  giving  raw 
milk,  may  now  be  considered  answered  in  so  far  that  no  recognizable 
advantage  is  seen  in  feeding  the  healthy  infant  raw  milk  rather  than 
Pasteurized  or  sterilized  milk.  The  theory  that  milk  becomes  unfit  for 
infant  feeding  by  brief  boiling,  seems  most  effectually  contradicted  by  the 
observation  that  human  milk,  even  after  boiling  ten  minutes,  is  as 
effective  in  relieving  seriously  ill  infants  as  is  the  mother's  milk  unboiled. 
On  the  other  hand,  the  view  is  justified  that  boiling  for  a  long  time  (^-1 
hour)  or  very  intense  heating  for  even  a  short  time,  causes  a  definite  dena- 
turization.  Clinical  experience,  at  least,  has  shown  that  the  excessively 
sterilized  milk  of  commerce  causes  anemia  and  under  certain  circumstances 
and  if  used  for  a  long  time  produces  scurvy. 

In  the  home,  only  Pasteurization,  that  is  heating  to  60°  or  65°  C, 
(140  °-160°  F.)  for  30  minutes  or  boiling  for  a  shorter  tune,  by  the  method 
to  be  discribed  are  to  be  considered.  Pasteurization  offers  no  advantage 
over  the  boiling  of  milk  for  infant  feeding  and  is  so  awkward  in  process  and 
so  uncertain  of  results,  even  with  the  best  apparatus,  that  it  has  never 
become  popular  and  cannot  be  recommended.  The  method  of  choice, 
therefore,  is  boiling.  It  is  of  no  importance  whether  the  whole  quantity 
intended  for  the  24  hours'  feeding  is  boiled  at  once,  in  a  glazed  or  enamel 
vessel,  or  whether  the  separate  feedings  are  boiled  in  the  bottles.  The  latter 
method  is  most  readily  accomplished  by  means  of  the  well-known  appa- 
ratus of  Soxhlet.  Instead  of  the  patent  rubber  cover,  which  is  drawn  in  by 
the  negative  pressure  as  the  bottle  cools  and  which  seals  the  bottle  hermeti- 
cally, a  metal  or  glass  cap  may  be  placed  over  the  mouth.  The  time  for 
boiling  may  be  gauged  by  allowing  ten  minutes  from  the  first  appearance  of 
steam.  By  sterilizing  the  separate  feedings,  every  possible  contamination 
by  later  handling  is  most  certainly  avoided;  but  the  likelihood  of  this  is 
sufficiently  reduced  by  boiling  the  entire  mixture  in  a  kettle,  if  everything 
else  is  cleanly.  In  this  method  of  minute  boiling  the  milk  may  be  kept  from 
running  over  by  using  a  double  boiler  or  one  of  the  various  milk  cookers 
with  perforated  cover.  In  every  case,  where  this  method  of  sterilization, 
without  immediate  bottling,  is  employed,  it  is  essential  to  cool  the  food  as 
rapidly  as  possible  by  placing  the  container  in  running  water  and  keeping  it 
iced.  In  order  to  accomplish  this,  with  the  use  of  small  quantities  of  cold 
water  or  ice,  Fliigge  has  recommended  a  cooling-box  constructed  upon  the 
lines  of  the  fireless  cooker. 

It  is  self-evident  that  the  physician  must  frequently  prescribe,  and 
often  in  detail,  the  methods  of  maintaining  absolute  cleanliness  of  all  the 
utensils  which  come  in  contact  with  the  infant 's  food.  Special  points  should 
be  emphasized.  All  portions  of  the  food  which  are  left  in  the  bottle,  after 
the  child  has  finished  nursing,  must  be  thrown  away  and  the  bottle  must 
be  washed  immediately  to  prevent  the  drying  of  particles  which  would 
then  be  difficult  of  removal.  The  nursing-bottle  and  nipple  with  rubber 
fittings  and  glass  tubing  should  be  absolutely  prohibited  because  it  cannot 
be  kept  clean.  The  simple  rubber  cap  nipple  is  best  cleaned  by  washing  it 


5$  TEXT-BOOK  OF  PEDIATRICS 

in  running  water  after  each  use  and  boiling  it  once  a  day.  In  the  intervals 
the  nipple  should  be  kept  dry  in  a  clean  covered  glass  or  cup,  rather  than  in 
an  antiseptic  solution. 

THE  TECHNIC  OF  ARTIFICIAL  FEEDING 

In  the  practice  of  artificial  feeding  from  birth,  no  food  is  given  during 
the  first  day  of  life  as  with  the  breast-fed  infant.  In  further  imitation  of  the 
natural  conditions,  only  three  or  four  feedings  are  given  during  the  second, 
third  and  fourth  days,  and  five  feedings  only  after  the  fourth  or  fifth  days. 
Nor  should  this  number  of  feedings  be  exceeded  later  on,  the  longer  time 
required  for  the  digestion  of  cow 's  milk  in  the  stomach  making  the  greater 
intervals  (preferably  4  hours)  necessary.  Artificial  food,  given  in  excess 
of  the  requirements  of  the  new-born,  is  much  more  dangerous  than  is 
human  milk. 

Since  the  caloric  values  of  cow's  milk  and  of  human  milk  are  approxi- 
mately equal,  it  might  seem  rational  to  give  the  infant  such  quantities  of 
undiluted  cow's  milk  as  are  taken  by  the  child  on  breast  feeding  and  this  is, 
indeed,  still  recommended  by  certain  authors.  The  preponderant  experience 
of  almost  all  physicians  has  shown,  however  that  good  results  may  be  more 
certainly  obtained  by  the  customary  use  of  milk  dilutions. 

The  researches  of  the  past  few  years  have  taught  that  the  advantage  of 
such  dilution  cannot  be  laid  to  the  indigestibility  of  the  casein  of  cow's 
milk,  for  this  has  not  been  proved.  On  the  contrary,  it  is  equally  question- 
able whether  the  avoidance  of  overfeeding  with  cow's  milk  of  so  reduced 
concentration  is  the  only  active  factor  of  benefit.  Probably  other  causes, 
which  cannot  be  considered  here,  play  an  important  role. 

The  reduction  of  the  food  value  which  results  from  dilution  may  not  be 
equalized  by  an  unlimited .  increase  of  quantity,  without  causing  injury 
through  the  excess  of  fluid.  It  is  customary,  therefore,  to  select  food  sub- 
stances which  may  be  added  to  the  diluent  to  equalize  or  diminish  this 
deficit.  Theoretically  and  empirically,  sugar  of  milk  seems  to  be  the  most 
acceptable  item  for  this  purpose.  Cow's  milk,  diluted  with  two  parts  of 
water,  to  which  has  been  added  one  level  teaspoonful  (3-4  grams)  of  sugar 
of  milk  for  every  100  c.c.,  (3J/2  ounces)  of  fluid,  is  to  be  recommended  for  a 
two-day-old  infant.  Even  if,  at  the  end  of  the  first  week,  the  infant  is  taking 
five  feedings  of  100  c.c.  (3J^  ounces),  each,  of  such  a  preparation,  its  actual 
food  value  is  so  low  that  the  danger  of  overfeeding  is  most  certainly  avoided. 
Indications  for  more  or  less  rapid  increase  of  the  food,  quantitatively  or 
qualitatively,  are  gained  by  observation  of  the  infant  in  regard  to  weight, 
stools  and  other  clinical  conditions. 

In  increasing  the  volume  of  the  feeding,8  to  meet  the  indications  of  need, 
we  have  a  relatively  definite  standard  in  the  volume  of  the  daily  food  taken 
by  the  healthy  breast-fed  infant  of  normal  weight  and  development. 

8  If  the  amount  of  each  feeding  is  to  be  measured  by  means  of  marks  on  the  nurs- 
ing-bottle, it  is  well  to  be  informed  as  to  the  accuracy  of  the  markings  represented 
by  each  line.  Even  with  bottles  of  the  same  model  it  is  impossible  to  depend  upon 
their  accuracy. 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT         59 

When  we  remember  that  the  daily  quantities  of  food  taken  represent 
one-fifth  of  the  body-weight  during  the  first  week  and  that  they  should 
gradually  sink  to  one-eighth  of  the  body-weight  by  the  end  of  the  first 
half-year  and  when  we  see  to  it  that  this  physiologic  volume  of  the  liquid 
food  is  not  exceeded  to  any  appreciable  extent  in  artificial  feeding,  we 
soon  find  it  necessary  to  increase  the  concentration,  that  is,  the  food  value 
of  the  dilution,  if  the  requirement  of  the  child  is  to  be  met. 

The  concentration  may  be  increased  either  in  definite  steps  by  passing 
from  the  proportion  of  one-third  to  one-half  and  later  to  two-thirds  of 
milk,  or  it  may  be  gradually  secured  by  adding  a  few  spoonfuls  of  milk 
without  changing  the  amount  of  water.  The  latter  method  seems  to 
resemble  more  closely  the  gradually  increasing  volume  of  food  which  the 
breast-fed  child  receives. 

Since  we  do  not  wish  to  give  undiluted  cow's  milk  during  the  first  month 
of  life,  and  it  has  proved  empirically  undesirable,  it  will  be  necessary  to 
increase  the  food  value  of  the  mixture  by  suitable  additions  and  this  is  done 
by  adding  fats  or  carbohydrates.  The  latter  need  is  met,  in  part,  by  the 
addition  of  sugar  of  milk  as  already  suggested.  The  fat  content  may 
be  increased  most  readily  by  the  addition  of  fresh  cream,  as  Biedert 
first  proposed. 

Because  ordinary  centrifuged  cream,  intended  for  the  use  of  adults, 
does  not  fulfill  the  requirements  of  milk  for  infant  feeding  in  the  matter  of 
freshness,  low  bacterial  count  and  special  selection  of  the  cattle  from  which 
it  is  taken,  it  is  better  to  prepare  the  cream  from  well-chosen  milk  at  home. 
For  this  purpose  the  milk  should  be  placed  on  ice  in  shallow  vessels  and  be 
allowed  to  stand  until  the  cream  has  separated.  After  the  milk  has  stood  for 
one  or  two  hours  an  approximately  10  per  cent,  cream,  or  about  100  cc. 
per  litre  of  milk,  may  be  obtained  by  careful  skimming. 

This  cream  forms  the  basis  for  Biedert's  "natural  cream  mixture. "  For 
its  graduation  to  the  age  of  the  child,  he  has  evolved  a  scheme  which  need 
not  be  given  here  because  it  is  not  commonly  used  for  feeding  healthy 
infants.  It  seems  more  practical,  without  reference  to  any  particular 
schedule,  to  add  to  the  diluted  milk  and  milk-sugar  mixture,  such  quantities 
of  fresh  cream  as  are  necessary  to  increase  its  food  value  to  the  desired 
degree,  as  may  be  borne  by  the  infant  without  gastro-intestinal  disturbance. 
Additions  of  cream  exceeding  a  total  3  per  cent,  of  fat  in  the  whole  mixture 
are  hardly  ever  beneficial  to  the  infant. 

The  ordinary  proprietary  preparations  present  absolutely  no  advantage, 
either  theoretically  or  in  their  practical  results  in  the  feeding  of  the  healthy 
infant,  over  the  milk  and  milk-sugar  dilution  mixed  with  fresh  cream.  That 
they  receive  high  recommendations  and  are  frequently  prescribed  by  mid- 
wives  and  physicians  is  due  to  the  facts  that  they  are  sold  with  directions  on 
the  container  and  that  no  special  knowledge  of  pediatrics  is  necessary  in 
dispensing  them.  The  thoughtful  and  conscientious  physician  robs  himself 
in  their  use  of  the  opportunity  of  changing  the  value  of  the  food  by  varying 
its  individual  components.  And  this  is  a  necessary  opportunity,  because 
the  mere  fact  that  the  coarse  chemical  composition  of  such  manufactured 


60  TEXT-BOOK  OF  PEDIATRICS 

food  is  roughly  similar  to  human  milk  does  not  make  it  at  all  the  equal  of 
breast-milk  in  value.  It  is  useful  only  with  those  children  who  would  do 
equally  well  upon  a  simple  milk  dilution  sweetened  with  sugar.  In  many 
other  children,  the  high  fat  and  sugar  content,  which  is  borne  without  the 
least  difficulty  in  the  form  of  human  milk,  causes,  with  these  preparations, 
diarrhoea  and  vomiting  and  permits  only  slight  increases  in  weight  which 
are  not  improved  by  increasing  the  quantity  of  the  food. 

Recently  Czerny  and  Kleinschmidt  have  put  forth  a  very  valuable 
method  of  utilizing  butter  fat  in  infant  feeding  by  their  method  of  pre- 
paring the  "Butter  Flour"  mixture.  By  this  method  it  is  possible  to  feed 
large  amounts  of  fat  to  very  young  and  poorly  nourished  infants  and  those 
which  are  difficult  to  feed  by  other  methods.  It  may  be  continued  for  long 
periods  and  the  gain  of  weight  and  general  development  is  comparable  to 
that  of  the  breast-fed  infant. 

The  food  consists  of  a  basic  diluent  prepared  as  follows:  Seven  grams 
butter  are  melted  over  a  slow  fire  allowing  it  to  fry  until  all  the  volatile  oils 
and  free  fatty  acid  is  evaporated.  Then  seven  grams  wheat  flour  is  stirred 
in,  allowing  the  mixture  to  brown  a  little.  To  this  mixture  is  added  100  c.cs. 
boiling  water  in  which  five  grams  granulated  sugar  has  been  dissolved. 
This  is  brought  to  a  boil,  strained  to  remove  any  lumps  and  cooled. 

A.  Graeme  Mitchell  recommends  the  following  practical  formula: 
Butter  2  level  tablespoonfuls,  flour  2l/2  level  tablespoonfuls,  sugar  1^ 
tablespoonfuls  and  water  10  ounces.  The  proportion  of  this  mixture  is 
constant  and  equals  26.6  calories  per  ounce. 

For  children  of  less  than  3000  grams  body-weight,  one-third  milk  isadded 
and  for  larger  infants  ^5  to  }/£  milk.  The  milk  should  be  certified  grade  or 
Pasteurized.  The  butter  is  sterilized  by  the  heating.  The  authors  advised 
200  c.c.  per  kilo  body- weight  per  day. 

Various  sorts  of  sugar  and  flour  in  the  form  of  gruel,  may  be  used  to 
increase  the  food  value  of  diluted  cow's  milk  and,  in  particular,  to  enlarge 
its  carbohydrate  content.  Of  the  former,  sugar  of  milk  has  been  repeatedly 
mentioned.  Soxhlet,  Heubner  and  Hofman  have  recommended  its  use  in 
such  quantities  that  the  food  value  of  the  milk,  lost  by  dilution  will  be 
restored.  To  do  this,  it  is  found  necessary  to  use  concentrated  solutions  of 
sugar  which  decidedly  exceed  the  physiologic  sugar  content  of  human 
milk  (6-7  per  cent.)9  It  is  doubtless  possible  to  feed  many  healthy  infants 
successfully  with  mixtures  containing  so  large  percentages  of  sugar  of  milk, 
but  it  must  be  emphatically  said  that  many  infants  will  not  tolerate  it  and 
that  it  will  not  produce  satisfactory  increase  of  weight.  For  this  reason,  it 
seems  advisable  to  limit  its  addition  so  that  the  entire  mixture  shall  not 
contain  more  than  6  per  cent,  inclusive  of  the  4  per  cent,  of  milk-sugar  con- 
tained in  the  cow 's  milk  itself  and  to  make  up  any  deficit,  if  necessary,  by 
concentrating  the  milk  or  by  adding  flour. 

Cane-sugar,  because  of  its  sweetening  power,  has  played  an  important 
role  in  the  artificial  feeding  of  infants,  even  before  the  science  of  pediatrics 

9  Milk-sugar  is  the  only  sugar  that  may  be  used  in  such  quantities  without  making 
the  solution  nauseatingly  sweet. 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT         61 

was  established  upon  a  scientific  basis.  In  young  infants  it  is  better  to 
avoid  it  and  to  substitute  milk-sugar  because  of  the  readiness  with  which 
cane-sugar  ferments;  but  in  older  children,  if  it  fall  short  of  such  concen- 
tration as  to  make  the  food  sickeningly  sweet,  it  is  often  well  tolerated. 

Malt  sugar  (maltose)  is  used  in  the  form  of  the  various  malt  extracts 
which  also  contain  dextrin,  nitrogenous  constituents,  water,  etc.,  but  it  is 
not  commonly  given  to  the  healthy  child.  In  the  feeding  therapy  of  sick 
infants,  it  plays  an  important  part. 

The  gruels,  representing  the  insoluble  carbohydrates  (polysaccharides) 
may  be  used  even  for  very  young  infants.  These  gruels  are  prepared  by  long 
continued  boiling  (3/^-1  hour)  of  either  oatmeal,  rolled  oats,  rice,  cracked 
or  crushed  barley,  etc.  The  quantity  of  each  of  these  cereals  required  for 
preparing  a  suitable  gruel  cannot  be  definitely  stated  because  of  the  vari- 
ability of  the  manufactured  products.  A  thin  gruel  should  remain  liquid 
when  cooled,  while  a  thick  gruel  should  gelatinize.  The  various  gruels  do 
not  in  themselves  present  any  essential  differences  in  their  use  for  infant 
feeding.  They  are  distinguished  from  the  flours  in  that  the  former  do  not 
consist  so  largely  of  starch,  but  contain,  also,  a  variable  but  greater  quantity 
of  vegetable  protein.  The  amount  of  solids  contained  is  low,  especially  in 
thin  gruels,  and  consequently  their  food  value  is  small. 

Of  the  flours,  we  must  consider  oatmeal,  which  is  distinguished  for  its 
content  of  over  5  per  cent,  of  fat,  wheat  flour  and  corn  flour.  Even  though  a 
large  amount  of  undissolved  residue  always  remains  in  the  preparation  of 
gruels,  which  should  be  separated  by  pouring  off  the  supernatant  fluid  or  by 
straining  the  gruel,  the  mixture  after  boiling  for  10  to  20  minutes,  contains 
exactly  the  same  amount  of  food  material  in  solution  or  rather  in  a  col- 
loidal state,  as  was  added  in  the  beginning.  The  food  value  of  these  gruels 
is  therefore,  high.  Corn  flour  considerably  exceeds  the  other  cereals  in  its 
solubility,  so  that  a  2  per  cent,  gruel  of  corn  flour  equals  a  5  per  cent, 
gruel  of  wheat  or  oat  flour  in  its  consistency. 

According  to  the  experimental  researches  of  Klotz,  the  various  flours 
show  important  differences  in  their  intestinal  digestion  as  well  as  in  their 
intermediate  metabolism.  It  would  appear  that  these  differences  do  not 
permit  the  several  flours  to  be  used  interchangeably  in  artificial  feeding; 
but  as  yet  no  definite  clinical  observations  are  at  hand.  Nevertheless,  a 
change  from  wheat  to  oat  flour,  or  vice  versa,  if  the  child  is  not  doing  well 
may  be  justified.  All  flours  have  an  extremely  low  content  of  mineral 
matter,  so  that  the  addition  of  a  small  amount  of  table  salt  (.3-. 5  per  cent.) 
to  all  gruels  is  necessary. 

In  the  practice  of  artificial  feeding,  it  is  well  to  avoid  the  addition  of 
flour  to  the  food  of  the  new-born  or  of  infants  in  the  first  two  or  three 
months.  I  feed  cereal  waters  at  the  end  of  the  first  month  and  believe  they 
are  well  digested  and  beneficial.  The  gruels  are  used  in  very  thin  form  at 
first  and  are  gradually  thickened,  and  this  only  if  sugar  of  milk  cannot  be 
used  successfully  which  is  often  possible  in  healthy  children  up  to  the  sixth 
or  seventh  month. 

Certain  limitations,  which  it  is  dangerous  to  exceed,  are  set  to  the  addi- 


62  TEXT-BOOK  OF  PEDIATRICS 

tion  of  flour,  even  after  the  third  or  fourth  month,  because  of  the  limited 
amylolytic  function  of  the  infantile  digestive  tract  and  the  too  great 
density  of  concentrated  flour  preparations.  Further  increase  of  the  food 
value  may  be  met  by  the  use  of  sugar. 

Toasted  and  baked  flours  in  which  the  starch  is  partially  dextrinized  by 
the  heat  and  is  thus  changed  into  a  soluble  form,  stand  in  close  relation  to 
the  simple  flours.  According  to  all  observations  recorded  to  the  present  time 
(Hedenius),  they  are  not  digested  any  better  by  young  infants,  but  rather 
not  so  well,  as  are  the  pure  flours.  Some  toasts,  especially  prepared  for 
infant  feeding,  contain  added  salts,  notably  calcium  phosphates,  but  no 
advantage  attaches  to  this  because  they  are  given  only  at  an  age  when  the 
child  receives  the  required  mineral  substances  in  soups,  vegetables,  or  fruit, 
and  in  much  more  natural  form  and  concentration.  The  numerous  proprie- 
tary infant  foods  should  be  avoided  in  the  feeding  of  healthy  children,  as  a 
matter  of  principle,  because,  on  the  one  hand,  they  serve  no  better  than 
simple  flour  or  sug^ar  and  because  advertised  as  the  best  or  the  only  sub- 
stitute for  mother's  milk,  they  are  responsible  for  many  dangerous  dietetic 
errors  and  for  their  invitation  to  the  weaning  of  many  children  whose 
mothers  are  able  to  nurse  them. 

A  peculiar  position  is  occupied  by  condensed  milk,  which  is  still  in  very 
general  use.  It  is  whole  milk  which  after  the  addition  of  large  quantities 
of  cane-sugar,  is  sterilized  and  condensed  to  a  paste-like  consistency. 
Certainly  it  is  no  better  for  feeding  healthy  infants  than  fresh  sweetened 
milk  dilutions.  It  should  be  given  only  temporarily  when  other  milk 
cannot  be  obtained  and  even  then  it  is  a  fair  question  whether  the  ex- 
cessive amount  of  sugar  present  may  not  be  harmful  to  the  child. 

The  food  requirement  of  artificially-fed  children  maybe  taken  as  approxi- 
mately the  same  as  that  of  breast-fed  infants  of  the  same  age  and  weight. 
Even  though  the  metabolism  of  the  breast-fed  infant  is  probably  maintained 
more  economically  as  we  have  shown  in  the  first  chapter,  it  must  still  be 
remembered  that  the  breast-fed  infant  is  able  to  stand  a  considerable 
amount  of  overfeeding  which,  in  the  artificially-fed  would  result  in  injury. 
We  may,  therefore,  transfer  the  caloric  requirements,  cited  for  breast-fed 
infants  on  page  22,  directly  to  the  artificially-fed  child  and  may  safely  go 
even  below  them. 

The  following  caloric  values  of  the  foods,  commonly  used,  may  serve 
for  comparison: 

Calories 

Whole  milk  per  litre 700 

Cream  10  per  cent,  per  litre  1300 

Flour  (100  gms.) 400 

Sugar  (100  gms.) 400 

From  these  few  equivalents,  the  caloric  value  of  a  food  mixture  may  be 
approximately  calculated  and  from  these  calculations  we  may  draw  con- 
clusions as  to  whether  the  daily  supply  of  food  con-tains  the  required 
number  of  calories.  By  way  of  example:  An  eight  weeks'  old  infant 
weighing  4500  gms.,  may  receive  five  feedings  of  280  c.c.,  or  a  daily  total 
of  900  c.c.,  of  a  mixture  consisting  of  one-half  milk,  one-half  water  and  20 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT         63 

grams  of  sugar  of  milk.  The  food  value  of  this  mixture  is  315+80  =  395 
calories.  In  this  mixture,  there  would  be  55  calories  less  than  the  required 
450,  a  deficit  which  could  be  made  up  by  six  grams  of  fat  contained  in  60  cc. 
of  10  per  cent,  cream,  or  by  14  grams  of  sugar.  Since  the  total  sugar  content 
would  be  18  grams  contained  in  the  milk,  +34  grams  added,  =52  grams  or 
5.8  per  cent.,  which  still  lies  within  permissible  limits,  the  latter  would  be  the 
easiest  way  of  adding  the  required  calories. 

While,  on  the  one  hand,  this  mathematical  method  aids  in  the  avoidance 
of  definite  errors,10  which  are  not  uncommon  in  the  choice  and  dosage  of 
artificial  food  mixtures,  yet,  on  the  other  hand  it  does  not  follow  that  food 
known  to  contain  sufficient  calories  will  necessarily  produce  the  proper 
development  of  the  child.  The  limitations  of  the  usefulness  of  the  caloric 
method  of  infant  feeding  have  been  already  discussed  in  Section  I. 

It  is  impossible,  therefore,  to  formulate  a  schematic  table  for  the  feeding 
of  the  healthy  infant,  much  as  this  trouble  and  thought-saving  device 
might  serve  for  the  busy  physician.  In  the  difficult  field  of  artificial  infant 
feeding,  which  requires  both  a  knowledge  of  theory  and  the  practice  of 
clinical  experience,  no  goal  can  be  successfully  reached  without  scientific 
observation  and  careful  consideration  of  each  individual  case. 

The  French  obstetrician,  Budin,  has  achieved  great  renown  by  his 
researches  in  the  physiology  of  infant  feeding.  He  has  instituted  the 
so-called  " Budin 's  factor,"  which  gives  a  reasonably  safe  standard  for  the 
quantity  of  milk  to  be  allowed.  He  proposes  that  the  artificially-fed  infant 
receives  about  10  per  cent,  of  his  body-weight  in  cow's  milk  daily.  To  this 
quantity  of  milk,  which  does  not  fully  meet  the  caloric  need,  may  be  added 
cream  or  sugar,  or  sugar  and  flour  to  balance  the  requirement. 

Pfaundler  has  devised  a  similar  schematic  formula;  as  follows:  "Take 
the  tenth  part  of  the  infant 's  body-weight  in  cow 's  milk  and  add  to  it  one- 
hundredth  part  of  its  body-weight  in  carbohydrate,  not  exceeding,  however, 
50  grams  a  day;  add  water  to  make  1  litre.  Divide  into  five  feedings  and  let 
the  child  take  as  much  at  each  feeding  as  it  will.  In  young  infants  the 
carbohydrate  may  be  given  in  the  form  of  milk-sugar  or  dextri-maltose ; 
in  older  children,  in  the  form  of  a  2  to  3  per  cent,  oatmeal  gruel  or 
a  3  to  4  per  cent,  flour  paste. "  This  formula  will  not  apply  in  all  cases. 
The  caloric  requirement  of  a  child  fed  with  food  prepared  according  to  this 
prescription  is  met  only  when  the  child  takes  relatively  larger  quantities 
than  a  breast-fed  child  of  the  same  weight  will  do.  This  is  usually  true  if 
the  feeding  intervals  are  not  intentionally  shortened. 

In  the  application  of  the  rules  for  the  feeding  of  normal  healthy  infants 
it  must  be  remembered  that  each  infant  must  be  fed  to  meet  its  individual 
requirements.  If  milk  dilutions  with  the  addition  of  carbohydrates  are 
used,  the  simplest  and  most  natural  standard  would  be  one  that  would  tell 
us  how  much  milk  and  carbohydrates  per  pound  or  per  kilogram  body- 
weight  the  baby  should  get.  To  be  exact  we  should  express,  or  at  least  be 
aware  of  the  number  of  grams  of  protein,  fats,  carbohydrates  and  salts  that 
the  infant  is  receiving  for  each  pound  of  its  body- weight.  We  believe  that 

10  Especially  the  errors  of  underfeeding. 


64  TEXT-BOOK  OF  PEDIATRICS 

if  statistics  on  infant  feeding  were  collected  on  this  basis  rather  than  in  per- 
centages of  the  ingredients  in  the  milk  mixtures  (the  total  mixture  being  of 
such  variable  quantity)  the  collected  data  would  be  far  more  valuable  as  a 
basis  for  future  work  in  infant  feeding. 

The  average  infant  fed  on  cow's  milk  will  metabolize  advantageously 
1.5  grams  of  protein,  1.5  to  2.0  grams  of  fat,  4.0  to  6.0  grams  of  carbohy- 
drates, including  that  contained  in  the  milk  and  cereal  for  each  pound  of 
body-weight. 

Feeding  the  following  amounts  of  the  milk  and  carbohydrates  will 
approximate  these  requirements  and  furnish  between  43  and  55  calories  per 
pound  body- weight: 

To  meet  these  protein  and  fat  requirements,  the  average  normal  infant 
will  require  each  day  a  minimum  of  1^  ounces  (45  milligrams)  of  cow 's  milk 
per  pound  of  body-weight. 

Infants  under  five  months  of  age  will  frequently  require  amounts  ap- 
proximating 2  ounces  (60  milligrams)  of  cow's  milk  per  pound  body- weight, 
except  during  the  first  few  weeks  of  life  when  smaller  quantities  of  whole  or 
skim  milk  are  indicated. 

In  beginning  feeding  with  cow 's  milk,  mixtures  must  always  be  started 
as  weak  formulae,  more  often  using  only  1  ounce  (30  milligrams)  of  cow's 
milk  to  a  pound  body-weight,  gradually  increasing  the  strength  to  meet  the 
infant's  needs. 

Underweight  infants  should  at  first  be  fed  according  to  their  present 
weight,  gradually  increasing  the  strength  of  the  mixture  as  rapidly  as  con- 
sistent with  the  baby's  ability  to  handle  the  diet,  and  thus  approximating 
the  needs  of  a  full  weight  baby  of  the  same  age.  These  babies  will  fre- 
quently take  over  2  ounces  (60  milligrams)  of  milk  per  pound  body- weight. 

With  the  institution  of  a  mixed  diet,  the  infant  thrives  with  less  milk 
per  pound  body-weight. 

From  birth  to  the  fifth  month  the  average  healthy  infant  may  be  satis- 
fied with  an  amount  of  food  approximating  2  ounces  more  per  feeding,  than 
the  infant  is  months  old. 

In  our  own  experience  we  have  found  that  a  concentrated  milk  mixture 
does  not  disturb  the  infant 's  digestion  when  the  milk  is  boiled  or  alkalinized. 

The  amount  of  water  is  calculated  by  multiplying  the  number  of  feedings 
by  the  amount  of  each  feeding,  and  subtracting  the  milk  to  be  given. 

Having  the  necessary  amount  of  milk  and  water,  we  ascertain  the  carbo- 
hydrate to  be  added. 

Cane  and  milk-sugar  are  added  in  such  quantities  that  the  normal 
infant  in  its  food  mixture  receives  a  total  of  from  4  to  6  grams  of  carbo- 
hydrates per  pound  of  body-weight  per  day,  including  that  contained  in  the 
milk  in  the  mixture.  As  \1A  ounces  of  milk  contains  approximately  2 
grams  of  lactose  it  will  be  necessary  to  add  from  2  to  4  grams  of  car- 
bohydrates for  each  pound  of  body-weight  to  the  diet  besides  that  con- 
tained in  the  milk.  One-tenth  of  an  ounce  (3  grams)  of  cane  or  milk-sugar 
per  pound  body-weight  answers  the  needs  of  the  average  normal  infant  in 
its  first  months. 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT         65 

Cereal  water  may  be  added  to  the  diet  after  the  infant  is  one  month  old. 
One-sixtieth  to  one-thirtieth  of  an  ounce  (0.5  to  1.0  gram)  of  starch  for 
each  pound  of  body- weight  may  be  added  to  the  mixture.  This  is  best 
given  in  the  form  of  cereal  waters  or  well-cooked  cereals. 

We  find  it  especially  valuable  in  those  cases  in  which  we  are  feeding  cane- 
sugar,  and  in  which  the  infant  takes  a  dislike  to  its  food  because  of  the 
intense  sweetness  of  the  mixture. 

In  underweight  infants  the  amount  of  sugar  and  cereal  to  start  with 
should  be  calculated  on  the  basis  of  the  present  weight,  approximating 
the  quantity  needed  for  a  full  weight  infant  as  rapidly  as  the  sugar 
tolerance  permits. 

When  more  than  one  quart  of  milk  mixture  is  needed  to  properly 
nourish  the  infant,  the  age  has  been  reached  when  a  mixed  diet  should  be 
instituted.  No  infant  should  be  fed  more  than  one  quart  of  cow 's  milk  in 
24  hours. 

It  is  to  be  remembered  that  the  amounts  of  food  recommended  are 
relative  and  must  be  increased  or  decreased  according  to  the  infant 's  prog- 
ress and  individual  needs. 

The  transition  to  mixed  feeding  is  conducted  similarly  in  method  with 
that  employed  in  breast-fed  infants,  in  that  the  child  is  given  cereal  soup 
prepared  with  broth  at  the  end  of  the  sixth  or  seventh  month,  this  food 
being  soon  followed  by  the  use  of  vegetables. 

In  estimating  the  result  of  the  feeding,  increase  in  weight  remains  the 
most  important  index  only  during  the  first  few  weeks  or  months.  The  older 
the  child,  the  more  particular  stress  is  to  be  laid  upon  other  factors.  This  is 
to  be  especially  emphasized  because  of  the  many  errors  that  are  made  in  this 
respect  in  the  nursery  since  the  practice  of  daily  weighing  has  become 
popular.  Of  more  consequence  than  the  absolute  gain  in  weight,  which 
usually  depends  upon  the  size  of  the  child  and  the  rapidity  of  its  growth,  are 
the  steadiness  of  this  gain,  the  muscular  tone,  the  turgor,  color,  bone  devel- 
opment, the  adequate  sleep,  the  good  disposition,  the  regularity  of  the 
bowels  and  bladder,  etc.  Excessive  fattening  should  be  especially  avoided 
in  artificially-fed  children,  because  such  constitutional  diseases  as  rickets, 
spasmophilia  and  the  exudative  diathesis,  take  a  more  severe  course  in  fat 
children  than  in  moderately  nourished  infants. 

During  the  second  year,  the  child's  protein  requirement  should  still  be 
largely  met  by  the  feeding  of  milk,  of  which  Y±  to  1  litre  (a  pint 
and  a  half  to  one  quart)  a  day  is  quite  enough.  During  this  period,  indeed, 
even  such  quantity  may  be  gradually  reduced  to  half  a  litre  (1  pint)  and 
replaced  by  other  foods.  As  in  the  first  year,  no  milk  should  be  given  at 
noon  either  with  the  meal  or  after  it.  The  menu  should  be  selected  accord- 
ing to  the  recommendations  on  page  51 ;  but  with  greater  latitude  in  the  use 
of  vegetables.  For  breakfast  and  in  the  afternoon,  the  child  should  receive 
200  c  c.,  or  at  most  250  c.c.  (7  or  8  ounces)  of  milk,  with  as  much  bread  as  it 
likes,  but  without  butter.  In  the  evening,  a  similar  quantity  of  milk  may 
be  given  with  a  cereal  (rice,  cornmeal,  etc.).  During  the  morning,  a  light 
lunch,  consisting  of  100  to  150  c.c.  (3-5  ounces)  of  milk,  may  be  served;  to 
5 


66  TEXT-BOOK  OF  PEDIATRICS 

which,  after  the  middle  of  the  second  year,  a  thin  slice  of  bread  or  a  rollr 
with  a  little  butter  and  fresh  or  stewed  fruits,  may  be  added. 

At  about  the  end  of  the  second  year,  the  quantity  of  milk  should  be 
gradually  reduced  further,  until  the  child  receives  only  a  small  supply  with 
its  breakfast,  when  the  protein  requirement  may  be  met  by  giving  a  little 
meat  and  egg.  In  view  of  the  much  greater  concentration  of  the  protein  in 
these  foods,  only  small  rations  of  them  are  required  in  addition  to  the 
vegetables,  legumens  and  fruits  necessary,  not  only  to  satisfy  the  appetite 
but  for  the  normal  mass  formation  of  the  feces  and  for  the  maintenance  of  a 
positive  alkali  balance.  Thus  the  diet  of  a  3-year-old  child  gradually 
approaches  that  of  the  adult  so  closely  that  particular  directions  no  longer 
seem  necessary.  Strong  spices  (mustard,  pepper,  etc.),  do  not  appeal  to  the 
taste  even  of  older  children  and  naturally  no  one  should  attempt  to  accus- 
tom the  child  to  them. 

THE  CARE  OF  THE  CHILD 

The  care  of  the  child  during  the  first  months  of  life  and  even  throughout 
the  entire  first  year,  provided  it  be  healthy  and  free  from  constitutional 
anomalies,  is  so  far  secondary  to  the  problem  of  feeding  that  breast-fed 
infants,  in  poor  and  unhygienic  surroundings,  often  thrive  and  develop 
better  than  do  the  artificially-fed  who  are  cared  for,  according  to  all  the 
rules  of  hygiene,  in  the  homes  of  the  wealthy.  That  despite  of  this 
warranted  assertion,  the  value  of  proper  hygienic  care  is  not  be  under-esti- 
mated, is  shown  by  the  greater  morbidity  and  mortality  among  artificially- 
fed  infants  of  the  poorer  classes  of  society,  as  compared  with  the  children  of 
the  educated  and  well-to-do.  After  the  completion  of  the  first  year,  when 
the  feeding  is  no  longer  of  preponderant  importance,  the  general  care  in  its 
broad  applications  is  of  larger  influence  upon  the  health  of  the  child. 

One  of  the  first  rules  in  the  care  of  infancy  and  childhood  is  cleanliness. 
At  the  outset,  it  involves  the  asepsis  and  uneventful  healing  of  the  umbilical 
wound.  The  mummification  of  the  umbilical  stump  is  best  accomplished  by 
the  use  of  such  drying  powders  as  bismuth  subgallate,  talcum  with  sodium 
salicylate,  sterilized  bolus  alba  and  the  like,' and  by  wrapping  the  stump  in 
sterile  gauze  or  absorbent  cotton.  Ointments  and  moist  dressings  are 
undesirable.  Certain  authors  advise  that  the  daily  bath  be  omitted  after 
the  first  cleansing  until  the  umbilical  wound  has  healed. 

Until  the  end  of  the  first  year,  or  until  the  child  has  acquired  habits  of 
cleanliness,  it  should  be  bathed  daily.  The  temperature  of  the  bath  should 
be  about  35  °C.  (95  °  F.),  at  first  and  may  be  decreased  by  2  °-3  °  C. 
(3°-5°  F.),  as  the  child  grows  older.  The  bath  should  not  be  continued 
longer  than  is  required  for  the  careful  cleansing  with  soap  and  water  of  the 
entire  body  and  especially  of  the  skin  folds  and  the  anal  region.  After  the 
bath,  the  parts  mentioned  should  be  scrupulously  dried  and  dusted  with  an 
inert  powder  (salicylic  or  zinc-oxide  powder,  or  even  rice  powder  or 
starchX  The  face  and  especially  the  eyes,  should  be  washed  with  fresh 
luke-warm  water  either  before  or  after  the  bath.  All  attempts  at  mouth 
cleansing  should  be  forbidden.  They  are  not  only  unnecessary  but  harmful 


CARE  AND  FEEDING  OF  THE  NORMAL  INFANT         67 

on  account  of  the  injury  to  the  mucous  membrane  which  may  result 
(Bednar's  aphthae).  After  all  the  incisors  have  appeared,  we  may  recom- 
mend that  the  teeth  be  cleansed,  at  first  with  a  soft  linen  cloth  and  later 
with  a  soft  brush.  Early  defects  should  be  looked  for,  because  the  timely 
treatment  of  the  milk  teeth  preserves  them  longer  and  gives  better  oppor- 
tunity for  the  development  of  the  permanent  set. 

The  deplorable  custom,  so  widespread,  of  permitting  the  child  to  form 
the  habit  of  sucking  a  pacifier  must  be  forcefully  combated.  The  pacifier 
is  not  only  unesthetic  but  dangerous,  on  account  of  the  frequency  with 
which  it  serves  as  the  carrier  of  dirt  and  disease  germs  from  the  pockets  of 
the  clothing,  from  the  mouth  of  the  mother,  who  at  times  moistens  it  with 
saliva,  and  from  the  floor  upon  which  it  may  fall,  etc.  Czerny's  statement 
that  there  are  constitutionally  restless,  neuropathic  infants  who  are  soothed 
most  readily  by  the  pacifier — and  harmlessly,  provided  it  be  kept  clean 
and  does  not  contain  sugar,  is  true;  but  the  number  of  such  children  is 
small  and  does  not  justify  the  widespread  abuse  of  an  undesirable  method 
of  quieting  a  child. 

The  infant  should  be  changed  before  each  feeding  and  should  be  washed, 
dried  and  powdered  carefully  every  time  it  is  soiled  by  a  fecal  discharge. 
In  cleansing  the  anal  region  in  girls,  the  parts  should  always  be  cleaned 
from  before  backward,  since  particles  of  fecal  matter  may  easily  be  carried 
into  the  gaping  vulva  and  especially  into  the  urinary  meatus,  eventually 
causing  infection.  At  the  slightest  indication  of  chafing  it  is  well  to  cover 
the  parts  with  oil  or  petrolatum,  or  better  with  a  thin  layer  of  zinc  oxide 
ointment,  to  protect  them  from  the  irritation  of  repeated  wetting. 

The  healthy  infant  maintains  his  normal  temperature  when  he  is 
dressed  in  a  shirt,  gown  and  diaper  and  is  covered  with  a  light  down  quilt 
or  with  a  linen-covered  wool  blanket.  Applications  of  artificial  heat,  in  the 
form  of  water  bottles  and  the  like  are  not  necessary.  The  room  temperature 
should  be  19°  to  20°  C.,  (66°  to  68°  F.)  as  nearly  as  possible,  and  may  be 
even  a  little  less  for  older  children.  The  child  should,  under  all  circum- 
stances have  its  own  bed. 

The  use  of  the  cradle  has  rightfully  gone  out  of  fashion,  for  children  are 
easily  spoiled  by  becoming  accustomed  to  the  quieting  rocking  movement 
and  are  broken  of  the  habit  with  difficulty.  The  unquestionably  injurious 
effect  of  rocking,  belief  in  which  rests  upon  purely  theoretic  considerations, 
has  yet  never  been  demonstrated. 

If  care  is  taken  to  provide  for  the  plentiful  supply  of  fresh  cool  air 
to  the  nursery  by  the  necessary  oft-repeated  and  complete  airing  of  the 
room,  the  initial  attempt  to  take  the  infant  out  of  the  house  in  winter 
may  be  delayed  without  harm  to  the  child.  Older  infants  may  be  warmly 
dressed  and  taken  into  the  open  daily,  eve«  in  winter  when  the  temper- 
ature is  mild.  Later,  when  the  child  can  go  about,  it  is  better  to  let  it  walk 
and  run  than  to  take  it  out  in  the  go-cart.  Even  wet  feet  are  not  injurious 
so  long  as  the  child  is  in  motion.  Dry  shoes  and  stockings  should  be  put 
on,  however,  so  soon  as  the  child  gets  home. 


68  TEXT-BOOK  OF  PEDIATRICS 

Through  the  first  half-year,  the  child  should  be  taken  up  only  for  some 
such  definite  purpose  as  bathing  or  feeding;  and  otherwise  should  be  left 
to  itself  even  when  it  is  awake.  During  the  second  half-year  it  may  be  held 
and  allowed  to  sit  up  on  the  arm  or  in  the  lap.  This  gives  it  a  free  survey 
of  its  surroundings  and  exercise  for  its  muscles  while  the  natural  tiring 
which  results,  produces  sound  sleep.  The  first  attempts  at  standing  and 
walking  should  not  be  hastened,  nor  should  attempts  be  made  to  retard 
them,  since  no  dangerous  effect  upon  the  back  or  legs  is  to  be  feared.  The 
strengthening  of  the  musculature,  indeed,  rather  counteracts  the  tendency 
to  deformities.  In  carrying  an  infant,  care  should  be  taken  to  hold  the  child 
first  on  the  right  arm  and  then  on  the  left  in  order  to  prevent  the  develop- 
ment of  scoliosis.  If  the  child  is  permitted  to  sit  up  in  bed,  he  should  be 
laid  down  again  as  soon  as  he  betrays  by  any  abnormal  posture  the  first 
sign  of  tiring.  When  the  child  is  learning  to  walk,  a  pen  gives  him  the  best 


FIG.  10. — Nursery  pen  (Feer). 

outlet  for  his  activities.  The  floor  of  the  inclosure  may  be  formed  of  a  soft 
smooth  cover,  which  should  be  kept  scrupulously  clean.  The  walls  should 
permit  the  child  to  look  freely  out  as  in  the  nursery  pen  of  Feer,  shown  in 
Fig.  10. 

The  habit  of  cleanliness  is  dependent  upon  the  attention  and  care 
devoted  to  accustoming  the  child  to  the  control  of  bowels  and  bladder. 
It  may  be  earlier  developed,  therefore  when  an  efficient  nurse  has  the 
entire  care  of  the  infant  and  is  relieved  of  other  duties.  At  about  the  sixth 
month,  at  latest,  the  child  should  be  taken  to  the  toilet  or  placed  upon  a 
wide-rimmed  vessel  for  the  purpose  of  moving  the  bowels  and  emptying 
the  bladder.  Further,  the  child  should  be  watched  and  waited  upon  when  it 
expresses  a  desire.  The  rapidity  with  which  results  are  obtained  depends, 
in  part,  upon  the  skill  of  the  nurse  and  in  part  upon  the  individuality  of  the 
child  and  it  therefore  varies  greatly.  In  general  it  may  be  expected  that 
with  ordinary  care  the  child  of  normal  development  will  give  evidence  of  its 
bodily  needs  by  the  end  of  the  first  year,  and  that  within  a  short  time  later 


69 

it  will  learn  to  make  known  its  desire.  Even  then,  it  may  take  several 
months  before  full  control  of  its  habits  is  established.  If  proper  care  is 
given  to  the  child  and  success  is  not  attained  by  the  third  or  fourth  year 
pathologic  conditions  must  be  suspected. 

The  habit  of  obedience  in  the  child  and  of  subordinating  its  wishes, 
tendencies  and  desires  to  the  direction  of  its  elders  is  of  frequently  under- 
estimated importance  in  the  entire  future  training  of  the  child.  This  is 
secured  the  more  readily  by  a  quiet  and  purposeful  demeanor  upon 
the  part  of  its  instructors,  whereas  the  child  is  confused  and  injured  by 
moody  treatment  and  may  easily  acquire  an  unpleasant  and  unreason- 
able disposition. 

The  training  of  the  child  should  begin  with  the  day  of  its  birth,  and  the 
method  by  which  this  is  best  accomplished  is  classically  described  by  Czerny 
in  his  lecture  "The  Role  of  the  Physician  in  the  Training  of  the  Child." 
(Deuticke,  Leipzic  and  Vienna;  1911,  3rd  edition.) 


III.  GENERAL  SYMPTOMATOLOGY  AND  TECHNIC 
OF  EXAMINATION 

REVISED  BY 

L.  R.  LeBUYS,  B.  S.,  M.  D.,  F.  A.  C.  P., 

Professor  of  Diseases  of  Children,   School  of  Medicine,  Tulane  University  of  Louisi- 
ana, New  Orleans. 

THE  technic  of  the  examination  of  children  can  be  acquired  and  the 
valuation  of  its  findings  appreciated  only  by  practical  demonstration  in  the 
clinics.  The  instructions  in  the  following  chapter  presuppose  that  the  stu- 
dent has  mastered  the  methods  of  internal  medicine.  Only  such  methods 
of  examination  are  described  as  are  specific  to  the  child  and  especially  to  the 
infant.  A  few  suggestions  as  to  variations  in  the  interpretation  of  certain 
findings  are  offered. 

The  history  of  the  case  should  be  taken  before  the  examination  is  made. 
In  estimating  the  value  of  such  history,  careful  distinction  must  be  drawn 
between  the  parents '  actual  observations  and  their  attempted  explanations 
of  events  which  often  lead  to  misinterpretation,  since  they  are  based  upon 
preformed  ideas.  Indefinite  statements  as  to  symptoms — as  for  instance  in 
the  matter  of  convulsions,  the  indefinite  term  applied  to  varying  and  hetero- 
geneous symptom-complexes — should  be  cleared  up  or  elaborated  by 
precise  questioning.  If  possible,  the  question  should  be  asked  so  that  the 
mother  does  not  have  to  answer  by  a  statement  of  opinion  or  by  a  descrip- 
tion of  events,  but  rather  numerically  or  by  yes  or  no.  I  have  to  thank  my 
teacher,  the  late  Richard  Forster,  the  ophthalmologist,  for  the  suggestion  of 
this  method.  It  was  the  result  of  his  long  medical  experience.  By  this 
means  a  probable  diagnosis  will  soon  be  foreseen,  which  later  may  be  con- 
firmed or  modified  by  the  complete  history  or  by  the  examination  findings. 
As  compared  with  the  experience  of  the  adult,  there  is  a  monotony  in  the 
disease-picture  in  the  infant  which  makes  this  method  of  diagnosis  easier. 
This  fact  depends  upon  the  comparative  rarity  of  many  disease  conditions 
in  infancy  which  many  be  excluded  from  the  first. 

The  family  history  with  its  hereditary  tendencies  and  contributing 
factors,  as  also  the  history  of  the  previous  illnesses,  particularly  those  which 
may  predispose  to  subsequent  ailments,  are  frequently  of  considerable 
value.  The  history  of  the  present  illness  with  its  mode  of  onset  and  the 
appearance  of  its  symptoms  is  essential  to  a  proper  conclusion. 

Even  in  taking  the  history,  the  physician  is  often  able  to  form  a  certain 
impression  of  the  child  by  casual  observation,  which  is  all  the  more  valuable 
because  in  the  young  child  self-consciousness  and  intentional  deception  do 
not  play  any  confusing  part.  The  posture  and  behavior  of  the  child,  the 
expression  of  his  face,  etc.,  may  give  valuable  diagnostic  hints.  Soltmann, 
in  a  brilliant  study  of  the  facies  and  facial  expression  of  the  sick  child  has 
indicated  many  peculiarities  which  cannot,  however,  be  discussed  here. 
70 


SYMPTOMATOLOGY  AND  TECHNIC  OF  EXAMINATION    71 

The  actual  examination  should  be  thorough  and  the  beginner  should 
proceed  according  to  a  definite  plan.  It  is  advisable  to  examine  first  that 
part  of  the  body  or  that  organ  to  which  the  history  points.  The  parts  of 
the  examination  which  tend  to  excite  the  child,  to  cause  it  to  cry  or  to 
resist  the  examiner,  as  for  instance,  the  examination  of  the  throat  should  be 
left  to  the  last. 

The  color,  respiration  and  pulse  may  be  studied  and  an  estimation  of 
the  temperature  may  be  made  by  the  hand  before  the  child  is  undressed,  an 
event  which  may,  in  a  measure,  disturb  him.  For  complete  examination  the 
child  should  always  be  stripped;  infants  completely  and  at  once,  so  that  the 
entire  body  may  be  surveyed. 

At  this  time  observation  should  be  made  upon  the  skin,  state  of  nutri- 
tion and  development  of  the  patient,  condition  of  the  muscular  and  gland- 
ular and  bony  systems.  The  existence  of  abnormalities  should  be  looked 
for  and  a  thorough  inspection  of  the  external  genitalia  and  anus  should  be 
made.  The  motility  of  the  neck  and  spine  should  not  be  overlooked. 

After  this  he  may  be  again  covered  as  examination,  part  by  part,  permits. 

In  older  children,  the  consideration  of  modesty  may  make  it  necessary 
to  undress  them  little  by  little  as  the  examination  proceeds. 

The  examination  should  begin  with  the  determination  of  the  temper- 
ature which  for  accuracy  in  the  infant  should  be  taken  by  rectum.  The 
child  is  laid  upon  his  side  and  his  flexed  thighs  are  held  with  the  left  hand 
while  with  the  right  the  thermometer  is  inserted  into  the  rectum  as  far  as 
the  lower  edge  of  the  scale.  Another  position  is  one  in  which  the  patient 
is  placed  prone  upon  the  lap  of  the  nurse  with  his  feet  hanging  over.  The 
thermometer  is -inserted  into  the  rectum  as  usual.  This  position  is  espe- 
cially adapted  to  the  resisting  child.  It  should  be  held  in  place  several 
minutes,  the  so-called  "minute"  thermometer  requiring  2  or  3  minutes  and 
others  5  minutes  or  longer  until  the  column  of  mercury  remains  stationary 
for  1  minute.  With  an  accurate  minute  thermometer  the  allowance  of  an 
extra  half  minute  should  be  all  that  is  required.  It  is  unnecessary  to  lubricate 
the  bulb  of  the  thermometer.  Even  though  the  child  lies  perfectly  still,  the 
nurse  should  be  warned  against  fastening  the  thermometer  in  place  with  a 
diaper  or  in  any  other  fashion,  and  leaving  it  there,  since  an  unexpected 
movement  on  the  part  of  the  child  may  break  the  thermometer  and  cause 
injury  to  the  rectum. 

During  succeeding  years  the  rectal  temperature  remains  the  most  exact, 
although  after  infancy  in  very  unruly  children  it  may  be  taken  in  the 
inguinal  fold,  where  the  thermometer  is  placed  between  the  strongly  flexed 
thigh  and  the  abdomen.  After  the  eighth  or  tenth  year,  in  children  who  are 
extremely  emaciated,  the  axillary  temperature  may  be  accepted  as  fairly 
accurate.  It  should  be  remembered  that  in  infants  the  cooling  effect  of  a 
long  journey,  as  for  example  to  the  physician's  office,  is  often  sufficient  to 
conceal,  for  the  time  being,  a  high  temperature. 

The  number  of  times  the  temperature  should  be  taken  and  the  hour  of 
taking  it  should  be  prescribed  by  the  physician.  Usually  it  is  taken  in  the 


72  TEXT-BOOK  OF  PEDIATRICS 

morning  and  in  the  afternoon.    The  normal  range  of  temperature  has  been 
discussed  on  page   14. 

In  counting  the  respiration  and  the  pulse,  as  in  the  adult,  the  attention 
of  the  child  should  be  averted,  if  possible,  so  that  satisfactory  results  may 
be  obtained  while  he  is  quiet.  The  most  accurate  information  is  obtained 
while  the  patient  is  aslf  ep.  The  only  quality  that  can  be  definitely  deter- 
mined in  the  peripheral  arterial  pulse  is  the  frequency.  When  awake  the 
pulse  may  be  considerably  accelerated  by  excitement  or  upon  the  approach 
of  the  physician  or  a  stranger. 

Conclusions  as  to  the  force  of  the  heart-beat  must  be  determined  by 
direct  auscultation  of  the  heart  sounds. 

The  size,  weight,  growth  and  development  should  be  carefully  observed 
and  compared  with  the  normal  average,  inasmuch  as  nutritional  disturb- 
ances may  influence  these  factors  considerably.  These  disturbances  with 
their  far-reaching  effects  should  be  constantly  kept  in  mind  for  their  influ- 
ence upon  the  future  of  the  individual. 

Head  and  Neck. — In  palpating  the  back  of  the  cranium  for  craniotabes, 
the  head  is  taken  firmly  between  the  palms  of  the  hands  which  are  applied 
flat  to  either  side  of  it  leaving  the  fingers  free,-  for  palpating  movements  to 
discover  soft  spots.  The  same  method  is  employed  in  palpating  all  other 
parts  of  the  head  and  especially  the  great  fontanelle.  In  estimating  the 
tension  of  the  latter,  it  must  be  remembered  that  crying  and  straining  of  the 
child  may  increase  the  pressure  even  under  normal  conditions.  The  size 
of  the  fontanelle  should  be  measured  diagonally,  the  results  being  stated 
either  in  centimeters,  inches,  or  finger-breadths  which  latter  usually  is 
sufficiently  accurate.  The  size  of  the  cranium  is  commonly  measured  only 
in  the  greatest  horizontal  circumference  and  is  considered  in  comparison 
with  the  circumference  of  the  chest,  measured  with  the  arms  extended, 
immediately  below  the  scapular  angles  and  over  the  nipples.  In  the  new- 
born the  circumference  of  the  head  is  the  greater,  but  at  one  and  a  half 
years  the  circumference  of  the  chest  becomes  equal  and  never  again  falls 
below  it. 

The  following  table  gives  several  average  measurements:  — 

Circumference  of  head.    Circumference  of  chest, 

Centimeters  Inches  Centimeters  Inches 

End  of  the  1st  month 35.4  13.95  34.2  13.46 

End  of  the  6th  month 42.7  16.8  41.0  16.1 

End  of  the  12th  month 45.6  18.0  46.0  18.1 

End  of  the  2nd  year 48.0  18.9  47.3  18.6 

End  of  the  3rd  year 48.5  19.0  48.0  18.9 

End  of  the  4th  year 50.0  19.68  49.0  19.2 

End  of  the  6th  year 50.9  20.0  54.8  21.5 

End  of  the  9th  year 51.7  20.35  00.2  23.7 

End  of  the  12th  year 52.3  20.58  65.0  25.6 

For  the  inspection  of  the  throat  the  child  is  laid  upon  the  bed  or  upon  the 
nurse's  lap,  his  hands  being  held  firmly;  the  physician  grasps  the  head  from 
behind  with  his  left  hand  and  introduces  the  tongue-blade  or  spoon-handle 
with  his  right.  This  gives  him  full  power  to  turn  the  head  of  the  child  so 
that  the  light  will  fall  into  the  mouth.  If  the  child  bites  the  tongue-blade 
the  physician  waits  patiently,  pressing  gently  upon  the  blade  until  the 


SYMPTOMATOLOGY  AND  TECHNIC  OF  EXAMINATION    73 

child  lets  go,  and  then  pushes  the  instrument  rapidly  toward  the  posterior 
pharyngeal  wall  keeping  the  tongue  well  down.  The  touch  of  the  instru- 
ment on  the  walls  of  the  pharynx  will  stimulate  the  gagging  reflex  and 
force  the  child  to  open  the  mouth  wide. 

Probably  the  most  satisfactory  ways  in  which  to  hold  the  patient  for  the 
examination  of  the  throat  are  as  follows : — 

(1)  Hold  the  patient  with  his  back  against  the  chest  of  the  nurse  with 
the  back  of  his  head  against  her  right  shoulder.  Her  left  arm  is  held  firmly 
about  the  patient  against  her  over  the  patient's  lower  abdomen.  Her  right 
arm  held  firmly  also,  is  placed  around  the  patient's  arms  at  about  the  level 


FIG.  11. — The  depressor  is  introduced  just  far  enough  to  hold  the  tongue  down. 

of  his  elbows,  pinioning  his  arms  tightly  against  his  sides.  The  head  is  then 
grasped  by  the  examiner's  left  hand  and  may  be  moved  in  any  direction 
desired,  when  the  tongue  depressor  is  introduced  into  the  mouth  (Fig.  12). 
The  depressor  is  introduced  just  far  enough  to  hold  the  tongue  down  out 
of  the  way  so  the  examination  may  be  clearly  made;  in  this  way  a  definite 
idea  is  had  of  the  conditions  existing.  If  it  is  desired  to  cause  gagging  the 
tongue  depressor  may  be  passed  further  back  so  as  to  produce  the  desired 
effect.  This  method  of  holding  the  patient  may  be  employed  either  with 
the  nurse  sitting  or  standing.  The  other  method  (2)  is  employed  when  the 
patient  is  too  ill  to  be  raised  out  of  bed  or  if  the  examiner,  for  any  reason, 
wishes  to  make  the  examination  with  the  patient  in  the  recumbent  position. 
The  patient  is  placed  flat  on  his  back,  his  arms  are  extended  horizontally 


74 


TEXT-BOOK  OF  PEDIATRICS 


above  his  head  on  a  line  with  the  bed.  The  nurse  holds  the  arms  tightly  so 
that  the  head  is  secure  between  the  arms  (Fig.  11).  The  examiner  pro- 
ceeds as  above.  In  both  methods  the  feet  may  be  readily  controlled. 
Direct  lighting  or  reflected  light  may  be  employed. 

Holding  the  nose,  or  any  other  attempt  at  force  is  unnecessary  and  has  a 
very  bad  effect  on  the  parents.  The  tongue-blade  to  be  used,  in  preference 
to  the  common  thick  glass  form,  is  the  smooth  metal  spatula  best  made  of 

nickel  which  does  not  rust,  or  of  nickeled 
wire  according  to  the  description  of  von 
Pirquet.  Wooden  blades,  which  may  be 
thrown  away  after  a  single  use,  are  very 
clean,  but  if  not  carefully  prepared  and 
the  edges  left  rough  may  injure  the  mouth 
of  the  child  who  resists  examination. 
When  it  is  necessary  for  further  inspection 
or  digital  examination  a  mouth  gag  may 
be  used.  The  Dwyer,  or  the  self -retaining 
Whitehead  model  will  serve. 

In  making  a  digital  examination  for  the 
determination  of  the  existence  of  adenoids, 
the  patient  is  held  with  his  head  pressed 
firmly  against  the  left  side  of  the  examiner 
by  the  examiner's  left  hand;  the  forefinger 
of  the  left  hand  of  the  examiner  presses 
the  left  cheek  of  the  patient  in  between  the 
teeth  when  the  mouth  is  open.  The  right 
forefinger  is  then  passed  into  the  mouth 
and  behind  the  soft  palate  making  a 
thorough  examination  of  the  pharynx. 
The  tendency  of  the  patient  is  to  close  the 
mouth.  In  doing  so,  however,  the  teeth 
come  in  contact  with  the  inner  wall  of  the 
cheek  and  this  affords  protection  to  the 
examiner's  right  forefinger  (Fig.  13.) 

Laryngoscopic  examination  is  difficult 
in  young  children.  According  to  Roth, 
the  mirror  must  be  set  at  a  more  acute  angle  (100°  instead  of  135°)  than 
in  the  adult.  Many,  however,  prefer  the  latter.  Anaesthesia  of  the  throat 
with  cocaine,  novocaine  or  the  like  can  hardly  ever  be  avoided.  Broncho- 
scopy  according  to  Kirstein's  method  is  possible  only  with  extra  small  in- 
struments and  after  much  practice;  even  then  it  fails  with  some  infants.  In 
case  of  necessity,  the  examination  must  be  done  under  complete  ansesthesia. 
According  to  Lynch,  ansesthesia  of  the  throat  for  laryngoscopic  exam- 
ination is  never  necessary,  on  the  other  hand,  bronchoscopic  examination 
should  always  be  done  under  general  ansesthesia  and  the  latter  examination 
should  never  fail,  instruments  smaller  than  those  ordinarily  employed  in  the 
adult,  being  used,  but  not  extra  small  ones. 


FIG.  12. 


SYMPTOMATOLOGY  AND  TECHNIC  OF  EXAMINATION     75 


Anterior  rhinoscopy  and  otoscopy  is  performed  as  in  the  adult,  but  of 
course  with  relatively  small  specula.  It  is  usually  necessary  to  remove  all 
particles  of  cerumen  from  the  infant's  small  auditory  canal.  The  sharp 
angle  of  the  tympanic  membrane  to  the  direction  of  the  canal  makes  the 
picture  less  definite.  However,  by 
pulling  the  lobe  of  the  ear  down- 
ward, thereby  straightening  the 
external  auditory  canal,  the  exam- 
ination of  the  tympanic  membrane 
is  considerably  facilitated. 

Pressure  upon  the  tragus  is  usu- 
ally sufficient  to  give  indication  of 
the  presence  of  an  acute  painful 
inflammation  of  the  external  audi- 
tory canal,  but  at  this  point,  as  in 
all  examinations  to  determine  the 
presence  of  pain,  one  must  be  cer- 
tain that  the  pain  is  local  and  is 
not  stimulated  by  fear  or  excited 
by  the  condition  of  the  child. 

The  examination  of  the  eye 
does  not  offer  any  technical  differ- 
ences from  that  employed  in  the 
adult.  The  ophthalmoscopic  ex- 
amination is  best  made  With  the 

/>Viilrl    Iviner    iinnn    Vii« 
1    1ym^    UP° 


rm 


FIG.  13.—  In  making  a  digital  examination  for  de- 
termination  of  adenoids  hold  the  patient  with  head 
pressed  firmly  against  left  side  of  examiner. 


bed  or  upon  the  nurse's  lap.     If 

necessary  it  should  be  done  after  dilatation  of  the  pupil  with  homatropin. 

The  lids  may  be  separated  by  the  retractor. 

CHEST 

The  Examination  of  the  Heart.  —  The  apex,  beat  in  the  infant  is  ' 
not  normally  visible  and  can  be  felt  but  slightly  in  the  fourth  intercostal 
space,  half  a  centimeter  outside  of  the  nipple  line.  With  increasing  age,  it 
gradually  becomes  visible  and  changes  its  position  so  that  after  the  second 
or  third  year  it  is  found  in  the  fifth  intercostal  space,  continually  moving 
medially  until  puberty,  when  it  has  taken  the  position,  normal  to  the  adult, 
inside  of  the  mammillary  line. 

Bulging  of  the  precardia  should  require  the  exclusion  of  cardiac  disease, 
as  it  is  a  frequent  finding  in  such  conditions  in  early  life. 

Percussion  of  the  cardiac  area  of  the  infant  gives  but  indifferent  infor- 
mation as  to  the  size  of  the  heart  and  permits  of  definite  conclusions  only  in 
the  event  of  great  enlargement.  Mediate  percussion  with  the  fingers  should 
always  be  employed  and  should  be  very  light.  It  is  best  done  with  the  child 
in  a  sitting  posture,  since  when  the  child  lies  on  his  back  the  heart  sinks  away 
from  the  thoracic  walls.  In  the  infant,  the  relative  dulness  extends  one- 
half  centimeter  to  the  left  of  the  mammillary  line  to  the  second  rib  above, 


76  TEXT-BOOK  OF  PEDIATRICS 

slightly  beyond  the  right  sternal  margin  on  the  right  and  to  the  fourth 
intercostal  space  below.  The  absolute  dulness  covers  only  a  small  area  to  the 
left  of  the  sternal  margin.  The  relative  dulness  diminishes  with  increasing 
age,  becoming  narrower  to  the  right  and  extending  by  one  intercos- 
tal space  in  the  downward  direction,  corresponding  with  the  gradual  sinking 
of  the  diaphragm  after  the  second  to  the  third  year.  The  absolute  dulness 
enlarges,  especially  to  the  left,  and  correspondingly  downward. 

Exploratory  puncture  of  the  pericardial  cavity  is  seldom  employed  for 
diagnostic  purposes,  but  may  be  done  as  a  therapeutic  measure. 

A  slight  sternal  dulness  over  the  manubrium  may  be  frequently 
demonstrated  and  is  termed  the  thymus  dulness.  It  is  separated  from  the 
upper  border  of  the  heart  dulness  by  a  zone  of  clear  lung  resonance.  In  my 
experience  the  dulness  of  the  thymus  merges  into  the  cardiac  dulness. 
More  intense  sternal  dulness  is  undoubtedly  always  pathologic  and  may  be 
accompanied  by  a  bulging  of  the  upper  segments  of  the  sternum. 

Auscultation  gives  more  definite  results.  In  order  to  localize  the  indi- 
vidual tones  and  sounds  accurately,  it  is  well  to  use  an  instrument  rather 
than  the  naked  ear.  In  applying  a  solid  stethoscope  to  the  soft  thoracic 
wall  any  pressure  should  be  avoided  that  may  tend  to  make  the  child  rest- 
less. In  the  use  of  a  tube  stethoscope  the  sounds  are  subdued  and  less 
distinct.  With  the  phonendoscope,  or  any  similar  binauricular  the  sounds 
may  be  heard  very  distinctly,  but  the  user  must  grow  accustomed  to  the 
instrument  in  order  to  be  able  to  exclude  extrinsic  sounds.  The  heart 
sounds  of  young  children  are  as  a  rule  relatively  louder  than  in  the  adult 
and  more  sharply  defined  and  sudden.  At  the  apex  the  first  sound  is  dis- 
tinctly the  more  prominent  while  the  predominance  of  the  second  sound  at 
the  base,  physiologic  in  the  adult,  is  scarcely  or  not  at  all  demonstrable. 
On  account  of  their  volume,  the  heart-sounds  may  often  be  heard  distinctly 
outside  of  the  heart  areas,  and  at  times,  even  over  the  back.  If  the  respi- 
rations are  especially  rapid,  while  auscultation  of  the  heart  is  being  at- 
tempted, and  this  can  hardly  be  avoided  in  nervous  children,  the  so-called 
heart-lung  sounds  may  be  mistaken  for  actual  heart  sounds.  These 
complicating  sounds  are  hardly  ever  present  in  infants.  In  children, 
who  breathe  during  the  auscultation  of  the  heart  a  slight  imperfection  or 
splitting  of  the  sounds,  and  especially  of  the  first  sound  at  the  apex,  is 
common,  but  is  of  no  diagnostic  significance.  As  a  rule,  endocarditic 
disease  and  resulting  organic  lesions  are  rare  in  infants.  This  is  true,  also,  of 
accidental  sounds.  Every  loud  heart  murmur  should,  therefore,  arouse 
suspicion  of  a  congenital  lesion.  This  infantile  peculiarity  disappears 
progressively  between  the  fourth  and  the  sixth  year. 

Direct  auscultation  is  most  simply  done  with  the  naked  ear  and  serves 
well  in  infants,  during  the  first  month,  in  determining  the  force  of  the 
heart.  The  examination  with  the  stethoscope  is  much  to  be  preferred.  If 
the  force  is  lowered,  the  sounds  become  duller  and  more  subdued  until 
finally  only  a  dull  tone,  synchronous  with  the  first  or  muscle  sound,  is 
heard  at  the  apex.  In  the  young  infant,  this  method  of  examination  takes 
the  place  of  the  examination  of  the  radial  pulse  which,  on  account  of  its 


SYMPTOMATOLOGY  AND  TECHNIC  OF  EXAMINATION    77 

smallness,   does   not   permit   definite   determination  of   arterial  tension 
volume,  etc. 

Blood-pressure,  measured  with  the  usual  instruments,  gives  good  results 
only  with  older  children  and  should  be  interpreted  with  great  caution.  Its 
practical  diagnostic  value  is  slight. 

During  the  examination  of  the  lungs,  as  in  the  examination  of  the 
heart,  the  child  should  be  as  quiet  as  possible.  This  is  usually  best 
assured  when  the  child  remains  in  the  arms  or  upon  the  lap  of  the  mother; 
but  this,  again,  makes  it  difficult  to  secure  the  complete  symmetry  of 
posture  which  is  absolutely  necessary  to  accurate  comparisons.  It  is 
better,  therefore,  to  have  the  child  lying  on  his  back  upon  the  bed  when 
percussing  the  anterior  thoracic  wall  and  to  percuss  the  back  with  the 
child  in  a  sitting  position  or  while  lying  on  his  abdomen.  If  the  child  is 


14. — Percussion  of  chest  in  sitting  position. 


sitting  it  will  be  necessary  to  straighten  the  spine  by  gently  pulling  upward 
on  the  head,  as  is  shown  in  Fig.  14,  because  the  liver  and  diaphragm  are 
pressed  upward  and  to  the  right  by  the  kyphotic  posture  resulting  from 
the  sinking  down  of  the  weak  spine,  and  may  thus  cause  dulness.  In  the 
examination  with  the  child  prone  (Fig.  15)  which  is  especially  applicable 
to  young  infants,  the  breast  of  the  child  with  adducted  and  flexed  arms, 
rests  on  the  hands  of  the  nurse;  then  the  back  is  stretched  out  and  the 
examination  may  be  made  very  comfortably.  The  percussion  of  the  infan- 
tile thorax  must  be  done  very  gently,  finger  to  finger,  on  account  of  the 
great  flexibility  of  the  thoracic  walls.  When  dulness  or  increased  sense  of 
resistance  is  encountered  by  this  gentle  percussion,  the  force  of  the  stroke 
may  be  increased  in  order  to  arrive  at  a  conclusion  as  to  the  intensity  of 
the  dulness.  In  the  infant,  small  pneumonic  foci  either  do  not  change  the 
percussion  sounds  at  all  or  may  even  impart  a  tympanic  quality  to  it  on 
account  of  the  surrounding  lung  tissue.  For  this  reason,  any  marked  dul- 
ness which  remains  with  even  deeper  percussion  should  arouse  a  suspicion, 


78 


TEXT-BOOK  OF  PEDIATRICS 


at  least,  of  exudate.  In  percussing  children  who  are  screaming,  two  things 
are  to  be  noted;  first,  a  loud  "cracked  pot"  resonance,  which  often  sounds 
like  the  clink  of  coins  is  frequently  heard  over  areas  of  normal  lung  tissue 
and  especially  over  the  anterior  of  the  thorax.  Secondly,  the  increased 
tension  of  the  intercostal  muscles  during  crying  causes  a  reduction  of  the 
sounds  and  increases  the  sense  of  resistance,  both  of  which  disappear  in  the 
phase  of  inspiration.  This  fact  makes  it  possible  to  distinguish  between  the 
dulness  due  to  the  increased  tension  and  the  dulness  due  to  actual  diseased 
conditions  of  the  lung.  In  thoracic  exudation  the  percussion  sounds  of  the 
normal  side  also  frequently  show  changes. 

In  the  auscultation  of  the  lungs  in  the  young  infant  the  stethoscope  has 
always  given  the  most  reliable  information.     In  direct  auscultation  the 


FIG.  "15. 


child  may  very  properly  be  held  in  the  position  shown  in  Fig.  16,  which 
gives  the  physician  great  freedom  of  motion. 

In  auscultation  the  crying  of  the  child  does  not  usually  disturb  the  ex- 
aminer as  it  does  in  percussion.  In  fact  the  cries  rather  give  enlarged  oppor- 
tunity by  bringing  out  indistinct  sounds  which  can  be  heard  clearly  only  at 
the  height  of  the  inspiration.  It  may  be  necessary,  therefore,  to  excite  crying 
at  times.  The  breath  sounds  of  the  young  child  are  much  louder  and  more 
distinct  than  in  older  children  or  in  adults,  the  so-called  "puerile"  breath- 
ing; even  normal  expiration  is  distinctly  audible.  The  auscultation  phenom- 
ena in  the  infant  are  not  essentially  different  from  those  of  the  adult, 
aside  from  the  fact  that  a  certain  amount  of  practice  is  necessary  in  order 
to  distinguish  the  normal  breath  sounds  from  the  transmitted  sounds  of 
the  upper  respiratory  passages  by  which  they  are  accompanied  and 
sometimes  concealed. 

D'Espine's  sign  should  be  looked  for  while  examining  the  thorax. 
When  present  it  is  indicative  of  enlarged  bronchial  lymph  glands.  Finally, 
it  is  necessary  only  to  mention  that  at  this  age  bronchophony  is  often 
clearer,  and  appears  earlier  than  bronchial  breathing  in  pneumonia. 


SYMPTOMATOLOGY  AND  TECHNIC  OF  EXAMINATION    79 

Exploratory  thoracentesis  should  be  performed  wherever  flatness  exists. 
The  point  of  selection  when  the  flatness  is  general  should  be  in  the  posterior 
axillary  line  at  the  fifth  interspace  on  the  right  and  at  the  sixth  interspace 
on  the  left.  If,  however,  the  flatness  is  more  localized,  the  point  of  intro- 
duction of  the  needle  should  be  at  that  of  greatest  flatness. 

A  needle  sufficiently  large  so  as  not  to  become  blocked  by  particles  of 
pus  should  be  used,  preferably  one  of  about  one  millimeter  in  diameter  and 
it  should  be  introduced  from  one  to  two  centimeters.  The  procedure 
should  be  performed  under  aseptic  conditions.  In  order  that  the  pus  should 
not  be  missed  in  the  path  of  the  puncture,  the  piston  of  the  syringe  should 
be  slightly  withdrawn,  thereby  creating  a  little  suction  immediately  after 
the  needle  is  introduced  beyond  the  skin  layer.  The  needle  should  pass 
between  the  ribs  nearer  to  the  upper  than 
the  lower  border,  so  as  to  avoid  the  inter- 
costal artery.  The  child  should  be  in  a 
sitting  position  and  held  firmly;  the  hand 
on  the  affected  side  should  be  brought 
over  the  opposite  shoulder. 

The  Abdomen. — In  the  infant  the 
condition  of  the  abdominal  wall  offers 
important  points  in  diagnosis.  Abnormal 
laxity  of  the  walls  always  indicates  that 
the  diseased  condition  has  gone  on  for  a 
considerable  length  of  time  or  that  the 
attack  is  serious.  If,  at  the  same  time, 
there  be  extreme  emaciation,  it  is  possible 
to  see  the  peristaltic  movements  of  the 
intestine  through  the  abdominal  wall.  FlG  16._Direct  auscultation. 

The  peristaltic  waves  of  the  stomach 

in  the  instance  of  pyloric  obstruction  are  readily  seen  and  are  more  pro- 
nounced if  much  loss  of  weight  has  occurred. 

The  size  of  the  liver  and  spleen  can  be  determined  definitely  only  by 
palpation,  while  percussion  gives  uncertain  results.  In  the  infant  the 
liver  is  relatively  larger  than  in  the  adult.  Its  anterior  border  extends 
further  downward  and  under  normal  conditions  may  even  be  felt  distinctly 
below  the  costal  margin. 

It  is  not  true  that  every  spleen  that  is  easily  palpated  is  enlarged, 
since  it  may  have  a  normally  greater  mobility. 

The  kidneys  are  palpable  from  above  only  when  the  abdominal  wall  is 
very  thin  and  lax.  More  often  it  is  possible  to  locate  and  feel  the  lower  pole 
from  the  rectum,  as  they  are  extremely  movable.  This  condition  can  hardly 
be  said  to  have  any  pathological  significance. 

It  is  often  quite  difficult  to  demonstrate  any  localized  tenderness  to 
pressure  in  the  abdomen  of  the  child  during  the  first  year.  The  close 
observation  of  the  facial  expression  during  palpation,  and  of  other  reactions, 
as  for  instance,  the  position  of  the  legs,  the  gait,  the  maintenance  of  a 
certain  posture  upon  one  side  or  upon  the  abdomen,  are  more  important 


80 


TEXT-BOOK  OF  PEDIATRICS 


than  the  indefinite  and  unreliable  subjective  symptoms  of  these  small 
patients.  Otherwise  the  topographical  conclusions  which  may  be  drawn  from 
the  determination  of  a  circumscribed  area  of  pain  are  the  same  as  in  later 
life.  The  same  methods  are  used  as  in  adults  for  determining  the  position 
and  size  of  the  stomach  or  of  a  certain  portion  of  the  intestines.  The  technic 
of  the  use  of  the  stomach  tube  is  much  easier.  The  method  is  described 
under  lavage  of  the  stomach  on  page  113. 

The  methods  of  examination  of  the  gastric  contents  and  gastric  motility 
are  the  same  as  in  the  adult.  The  size  of  the  catheter  should  be  14  to  18 
French  scale. 

Abdominal  paracenteses  is  done,  diagnostically  only  to  secure  the 
fluid  for  bacteriologic  or  cytodiagnostic  examination.  The  point  of  selection 
for  the  introduction  of  the  needle  is  midway  between  the  pubes  and  the 
umbilicus.  The  procedure  is  done  under  aseptic  precautions.  The  needle 


FIG.  17. — Method  of  collecting  urine  from  a  male  infant.    Test-tube 
fastened  over  penis  by  means  of  adhesive  plaster. 

should  be  about  one  millimeter  in  diameter.  The  syringe  should  be  tested 
before  using. 

Catheterization  of  the  urinary  bladder  is  possible  in  the  infant,  but 
requires  some  practice.  In  boys  it  is  done  with  a  metal  or  elastic  catheter, 
the  caliber  of  which  should  correspond  with  that  of  the  urinary  meatus,  and 
in  girls  it  is  more  easily  done  with  a  metal  catheter  of  about  the  thickness  of 
knitting-needle.  When  necessary,  a  cystoscope  of  the  smallest  calibre 
may  be  introduced  under  anaesthesia  in  girls  at  the  end  of  the  first  year. 
A  paralysis  of  the  sphincter,  however,  will  remain  for  several  days,  so  that 
this  method  of  examination  should  be  used  in  cases  of  extremity  alone. 
Catheterization  of  the  ureters  is  technically  impossible  during  the 
first  year. 

When  urine  is  to  be  collected  for  examination,  the  danger  of  bladder 
infection  by  the  use  of  the  instrument,  even  under  proper  precautions  may 
be  easily  avoided  by  employing  instead  a  strong  test-tube  fastened  over 
the  penis  with  adhesive  plaster,  as  is  shown  in  Fig.  17.  In  girls,  a  small 
Erlenmeyer  flask  (Fig.  18)  may  be  placed  over  the  labia  which  have  been 
separated  and  carefully  cleansed. 

These  methods  of  collecting  urine  suffice  for  the  ordinary  routine  exam- 


SYMPTOMATOLOGY  AND  TECHNIC  OF  EXAMINATION    81 

ination,  but  where  it  becomes  necessary  to  determine  the  existence  of  a 
pyelitis  or  for  the  culturing  and  examination  of  the  urine  for  bacteria, 
catheterized  specimens  are  essential  except  possibly  in  the  male  patient, 
with  no  phimosis  and  an  easily  cleansed  glans  and  the  urine  voided  under 
direction.  The  first  several  streams  of  urine  should  not  be  collected,  as  they 
may  be  contaminated  with  washings  from  the  urethra.  When  properly  done 
the  possibility  of  infection  from  catheterization  is  practically  nil. 

Because  of  the  relatively  high  position  of  the  bladder  in  the  infant  cath- 
eterization may  become  necessary  at  times  to  differentiate  between  a  dis- 
tended bladder  and  ascites  or  a  new  growth. 

Rectal  examination  should  be  made  whenever  an  intestinal  obstruction, 
intussusception  or  an  obscure  abdominal  condition  may  exist.  The  exam- 
ination is  best  made  with  the  patient  lying  on  his  back,  the  oiled  finger 
being  inserted  into  the  rectum. 

The  Nervous  System. — In  order  to  test  the  passive  motion  and  the 
tendon  reflexes,  it  may  be  necessary  to  distract  the  attention  of  the  child 


FIG.  18. — Method  of  collecting  urine  from  female  infant.     Small  Erlenmeyer  flask 
or  large  test-tube  fastened  over  vulva. 

and  thus  diminish  the  increased  muscle  tone,  since  voluntary  tension  of  the 
musculature  in  nervous  children  often  makes  it  impossible  to  bring  out 
these  reflexes.  In  the  infant  this  is  most  easily  done  if  the  child  is  examined 
while  taking  his  food.  The  absence  of  the  patellar  reflex  when  these  pre- 
cautions are  taken,  is  always  pathologic.  Ankle  clonus  is  common  during 
the  first  year,  especially  in  feverish  or  excited  children,  without  having  any 
diagnostic  significance. 

Because  of  the  frequency  and  the  clinical  importance  of  spasmophilia 
in  infancy,  attention  must  be  called  to  its  symptoms  and  especially  to  the 
facial  and  peroneal  phenomena.  Special  discussion  of  these  is  to  be  found 
in  the  section  on  nervous  diseases. 

Of  the  various  tests  for  the  quality  of  sensation,  only  that  for  the  pain 
sense  can  be  applied  in  children  who  have  not  learned  to  talk,  and  even  this 
test  must  be  done  very  carefully  because  the  infant  is  often  so  alarmed  by  his 
first  experience  that  he  will  cry  out  to  non-painful  stimulation,  and  often 
at  the  mere  approach  of  the  examining  hand  or  when  he  is  but  gently 
touched.  The  final  findings  must  always  be  controlled  by  comparison  with 
normal  parts. 
6 


82  TEXT-BOOK  OF  PEDIATRICS 

Electrical  tests  are  applied  as  in  the  older  person.  Despite  the  smallness 
of  the  child  the  stimulating  electrode  should  be  of  the  same  size  as  that  used 
in  the  adult  (a  Stintzing  normal  electrode  one  cm.  square,  see  Diseases  of 
the  Nervous  System)  so  that  the  results  of  the  reactions  at  all  ages  may  be 
directly  compared.  A  plate,  fifty  centimeters  square,  may  be  used  for  the 
indifferent  electrode  which  should  be  placed  over  the  breast  or  abdomen. 
The  technic  of  the  examination  requires  not  only  a  certain  amount  of 
practice  but  also  close  attention,  if  voluntary  muscular  contractions,  inde- 
pendent of  the  electric  stimulus,  are  not  to  lead  the  observer  into  error. 

Lumbar  puncture  is  of  extraordinary  diagnostic  value  in  children  as  it 
is  in  later  life,  but  it  is  done  much  more  frequently  on  the  infant  because, 
on  the  one  hand,  of  its  simplicity  of  technic,  and  on  the  other  hand, 
because  the  greater  elasticity  of  the  cranial  wall  entirely  relieves  it  of 
danger.  The  most  satisfactory  instrument  is  a  trocar  of  about  the  size  of  a 
knitting-needle.  Only  in  case  of  necessity  should  a  heavy  hypodermic 
needle  be  used,  because  in  the  use  of  the  trocar  all  danger  of  injury  is 
avoided  after  the  stylette  has  been  withdrawn.  Many  prefer  needles  to 
trocars.  The  size  of  the  needle  depends  upon  the  size  of  the  patient. 

Aspiration  of  the  fluid  by  means  of  a  syringe  is  frequently  not  only 
useless  but  dangerous  and,  therefore,  should  never  be  attempted. 

The  pressure  is  measured  either  by  means  of  a  long  tube  of  small 
calibre,  according  to  Quincke,  which  is  attached  to  the  trocar  by  means  of 
rubber  tubing;  or  by  the  method  of  Pfaundler,  with  a  manometer  filled  with 
mercury  or  salt  solution.  By  the  first  method  we  actually  measure  the 
pressure  after  a  certain  amount  of  the  fluid  has  been  withdrawn;  and,  as  a 
result,  lower  figures  are  obtained  than  by  the  second  means — the  result  of 
which  can  be  calibrated  only  by  comparison  with  those  obtained  with 
similar  apparatus.  It  is  to  be  further  noted  that  the  pressure  is  naturally 
lower  when  the  patient  is  lying  down  than  when  he  is  sitting  up.  Sahli 
gives  from  69  to  100  or  150  mm.  water  pressure  (  =5  to  7  or  11  mm.  mer- 
cury), measured,  according  to  Quincke 's  method,  with  the  patient  lying 
down;  while  Pfaundler,  with  the  iris  mercury  manometer,  has  found  20 
mm.  in  the  infant  and  25  mm.  in  children  of  from  two  to  twelve  years,  in 
an  upright  position.  In  comparing  Pfaundler 's  figures  with  those  taken 
by  the  hydrostatic  method,  values  of  from  12  to  19  mm.  mercury  are  ob- 
tained in  children  lying  down.  It  is  superfluous  to  say  that  the  mensura- 
tion, as  well  as  the  puncture  itself,  should  be  done  under  absolute  asepsis. 

Whenever  tumors  of  the  brain  are  suspected  the  lumbar  puncture  should 
be  carefully  performed,  with  the  patient  in  the  prone  position,  and  pref- 
erably with  the  head  lower  than  the  feet,  so  as  to  avoid  the  danger  of  a 
possible  damage  to  the  vital  centres  of  the  medulla  from  pressure  from 
above.  If  after  the  spinal  canal  has  been  reached  the  fluid  does  not  flow 
through  the  aspirating  needle  the  position  of  the  patient  should  be  gradu- 
ally changed  to  approach  the  sitting  posture  or  to  such  an  angle  that  will 
allow  the  fluid  to  flow  through  the  needle. 

In  making  the  puncture  with  the  child  lying  on  his  side,  which  position 
is  to  be  greatly  preferred  because  the  child  may  be  held  more  firmly, 


SYMPTOMATOLOGY  AND  TECHNIC  OF  EXAMINATION    83 

the  back  is  arched  as  much  as  possible  by  bending  the  head  forward  on  to  the 
breast  and  flexing  the  thighs  upon  the  abdomen,  as  is  shown  in  Fig.  19. 
The  point  of  entry  is  then  marked  by  connecting  the  iliac  crests  by  a  line 
and  by  locating  with  the  under  finger  of  the  left  hand,  the  inner-vertebral 
space  lying  nearest  this  line.  The  level  so  located  will  usually  be  the  fourth 
or  more  surely  the  third  lumbar  space.  In  young  children  it  is  not  well  to  go 
above  this  point,  on  account  of  the  fact  that  the  spinal  cord  extends  lower 
than  in  adults  and  may  therefore  be  injured  by  higher  puncture.  The 
entry  is  best  made  in  the  median  line  and  the  needle  should  not  deviate 


FIG.  19. — Position  for  lumbar  puncture. 

from  the  middle  plane,  but  should  follow  the  direction  of  the  spinous 
process  inclined  slightly  upward.  A  slight  decrease  of  resistance  may  be 
felt  the  moment  the  needle  enters  the  canal,  2-4  cm.  (^i-l/'i  inches)  beneath 
the  skin.  At  this  point  the  trocar  should  not  be  pushed  any  further  on 
account  of  injuring  the  large  venous  plexes  on  the  anterior  wall  of  the  canal. 
Even  though  the  hemorrhage  caused  by  such  an  injury  is  not  at  all  danger- 
ous, the  admixture  of  blood  with  the  spinal  fluid  is  very  disturbing  and  may 
even  make  the  specimen  entirely  useless  for  examination.  The  cerebro- 
spinal  fluid  begins  to  drop  from  the  trocar  immediately  after  the  stylette 
is  withdrawn,  if  the  puncture  has  been  properly  performed.  If  the  pressure 
is  increased  it  may  flow  out  in  a  steady  stream.  If  the  opening  of  the  trocar 


84  TEXT-BOOK  OF  PEDIATRICS 

is  blocked  by  a  root  of  the  cauda  equina  a  slight  movement  of  the  needle 
will  often  cause  the  flow  to  begin.  If  no  outflow  appears,  in  spite  of  the  fact 
that  the  needle  has  been  properly  introduced  (a  dry  puncture)  it  may  be  due  to 
the  abnormal  viscosity  of  the  highly  fibrinous  cerebrospinal  fluid,  which 
cannot  pass  the  fine  calibre  of  the  needle.  In  such  an  event  the  injection 
of  a  few  cubic  centimeters  of  sterilized  physiologic  salt  solution  will  often 
dilute  the  fluid  sufficiently  to  permit  enough  to  flow  off  for  purposes 
of  examination.  Great  caution  should  be  exercised  so  as  not  to  produce 
additional  pressure  when  there  is  already  an  increased  intercranial  pressure. 

A  few  cubic  centimeters  (5-10)  of  the  fluid  will  suffice  for  examination. 
In  cases  where  the  pressure  is  increased  larger  quantities  may,  of  course,  be 
removed,  continuing  so  long  as  there  is  a  free  flow.  After  the  needle  has  been 
withdrawn,  the  puncture  wound  is  covered  with  sterilized  gauze  fastened 
with  adhesive.  The  method  of  examination  of  the  fluid  and  the  conclusions 
to  be  drawn  from  the  results  of  examination  are  given  in  a  special  chapter. 

Cranial  puncture,  a  diagnostic  measure  which  in  the  adult  is  rapidly 
gaining  importance,  may  be  done  all  the  more  easily  in  the  infant  because  it 
is  unnecessary  to  trephine.  It  is  usually  possible  to  puncture  the  thin 
cranial  wall,  or  rather  the  membranous  fontanelle,  very  readily  with 
the  trocar.  The  puncture  is  made  1-2  cm.  (0.4-0.8  inch)  to  one  side  of  the 
sagittal  suture  at  the  top  of  the  head  or  slightly  anterior  to  it  and  preferably 
in  the  area  of  the  fontanelle.  The  trocar  is  inserted  perpendicularly  to  the 
tangential  planes  for  a  short  distance  only  and  the  stylette  is  withdrawn  to 
note  whether  fluid  is  present  at  this  level.  Many  prefer  the  use  of  a  needle 
to  that  of  a  trocar. 

Fluid  at  this  point  indicates  an  external  hydrocephalus.  If  there  is  no 
fluid  the  needle  is  pushed  in  a  few  centimeters  further  in  the  direction  of 
the  lateral  ventricles.  In  older  children  with  a  completely  ossified  cranium, 
it  is  necessary  to  trephine.  The  removal  of  the  hair,  which  is  necessary 
before  preparing  the  field  of  operation,  may  be  done  much  more  easily  in 
young  children  by  using  a  depilatory,  applied  to  the  skin  for  a  few  minutes 
in  the  form  of  a  freshly  prepared  paste,  than  by  shaving  the  scalp. 

Stools. — The  physician  usually  sees  the  bowel  movements  of  infants 
upon  the  diaper  and  often  they  are  not  very  fresh.  It  is  necessary  to 
remember  that,  on  account  of  the  drying,  thin  stools  may  appear  more  solid 
than  they  were  when  fresh  and  that  the  green  color  so  frequently  seen  may 
be  reasonably  due  to  the  oxidizing  influence  of  the  air,  and,  therefore,  is  of 
no  clinical  significance. 

Sputum. — On  occasion,  and  especially  where  there  is  an  open  tubercu- 
lous lesion,  the  examination  of  the  sputum  may  be  of  great  clinical  interest 
even  in  children  of  early  years  who  always  swallow  their  sputum.  In  these 
cases  it  may  be  secured  for  examination  or  for  culture,  by  passing  a  tongue- 
blade  far  back  in  the  throat  and  catching  the  sputum  thrown  up  by  the 
coughing  on  the  blade  or  on  an  applicator  covered  with  cotton.  This 
method  is  much  more  simple  and  more  successful  than  the  difficult  search 
in  the  feces  for  tubercle  bacilli  swallowed  with  the  sputum. 


SYMPTOMATOLOGY  AND  TECHNIC  OF  EXAMINATION    85 

Blood. — The  blood  of  young  children,  to  be  used  for  microscopic  exami- 
nation is  preferably  taken  from  a  toe,  usually  the  great  toe,  or  from  the  ear 
rather  than  the  finger-tip.  When  larger  quantities  are  required  (2-5  cc.) 
for  serum  diagnosis,  as  for  instance  in  the  Wassermann  reaction,  a  super- 
ficial vein  may  be  punctured.  For  this  purpose  one  of  the  superficial  veins 
of  the  head  is  better  than  the  veins  of  the  arm.  A  cupping  glass  may  be 
used.  For  this  purpose,  one  or  two  long  incisions  (!-!}/£  cm.)  are  made  over 
the  back  and  a  cupping  glass  placed  over  them  is  permitted  to  draw  out  the 
required  amount  of  blood. 

Sinus  Puncture. — The  puncture  of  the  longitudinal  sinus  for  the  pur- 
pose of  obtaining  blood  and  for  the  injection  of  therapeutic  fluids  has  proved 
very  useful.  The  technic  is  quite  simple  and  free  from  danger.  A  Luer 
syringe  with  an  18  or  20  gauge  needle,  about  1^  inches  in  length  is  used. 
By  a  series  of  measurements  it  has  been  determined  that  the  sinus  lies 
He  to  ;h$  inch  beneath  the  surface  of  the  scalp  and  is  about  %2  of  an  inch  in 
calibre  at  the  posterior  angle  of  the  fontanelle.  For  this  reason  it  is  con- 
venient to  have  a  guard  firmly  fixed  about  %  inch  above  the  point  of  the 
needle  to  prevent  deeper  penetration.  Reports  tend  to  show  that  even 
though  the  sinus  be  transfixed  no  special  injury  results. 

Roentgen  Rays. — The  diagnostic  use  of  the  Roentgen  rays  is  hampered 
by  the  fact  that  many  parts  of  the  skeleton  which  are  not  completely  ossi- 
fied permit  the  passage  of  the  rays  fully  as  well  as  the  surrounding  soft 
parts.  The  comparison,  therefore,  with  radiograms  of  skeletons  of  normal 
infants  in  the  same  stage  of  ossification  is  always  unreliable  in  the  matter  of 
pathologic  findings.  In  the  recognition  of  alterations  in  the  internal  organs, 
for"  instance  of  enlarged  bronchial  lymph  nodes,  pneumonia  areas,  pleuritic 
exudates,  enlargement  of  the  heart,  etc.,  examination  with  the  Roentgen 
rays  has  gained  in  importance  in  pediatrics  as  well  as  in  internal  medicine. 
The  Roentgen  rays  are  of  great  value  in  the  determination  of  stenoses  and 
atresia,  as  for  example,  those  of  the  oesophagus,  stomach  and  intestines, 
also  for  obstructions  due  to  intussusception,  etc.  With  good  apparatus  and 
careful  technic,  changes  which  cannot  be  determined  by  other  means  may 
be  demonstrated  in  the  same  degree  as  in  the  adult. 


IV.  GENERAL  PATHOGENESIS 


MORTALITY  AND  MORBIDITY 

REVISED  BY 
B.RAYMOND  HOOBLER,  M.D., 

Professor  of  Pediatrics,  Detroit  College  of  Medicine  and  Surgery,  Detroit. 

THE  mortality  of  infants  and  children  is  of  great  significance  because  it 
exerts  a  pronounced  influence  upon  the  growth  and  quality  of  the  popula- 
tion upon  which  depends  the  expansion  of  a  Nation.  In  fact  the  infant 
mortality  rates  should  be  a  matter  of  national  concern. 

Table  I.  shows  in  outline  form  the  relation  between  the  birth  and  death- 
rate,  also  the  relative  high  mortality  of  the  first  year. 

TABLE  I. 


"Co.  of  Children 
Born  Alive  Per 
1000  inhab- 
itants 

No.  of  Deaths 
Per  1000  Inhab- 
itants 

Deaths  in  First 
Year  Per  1000 
Children  Born 
Alive 

No.  of  Children 
Born  Alive  Ex- 
ceeds No.  of 
Deaths  Per  1000 
Inhabitants 

France          

.1906 

19.6 
24.9 
25.6 
25.6 
26.2 
26.3 
28.3 
29.1 
31.0 
32.3 
32.4 
33.6 
37.0 
48.0 

19.3 
16.5 

13.7 
14.5 
13.5 
16.6 
13.3 
13.7 
17.1 
20.0 
21.4 
22.4 
25.1 
29.5 

143 

147 
85 
109 
76 
108 
123 
99 
170 
158 
148 
209 
212 
272 

0.3 
8.4 
11.9 
11.1 
12.6 
9.7 
15.0 
15.5 
13.8 
12.3 
11.0 
11.2 
11.9 
18.5 

Belgium  

.1908 

Sweden     

.1908 

England  (Wales)  . 
Norway  

.1909 
.1908 

Switzerland  

.1908 

Denmark      

.1908 

Holland 

.1908 

German  Empire.  . 
Japan  

.1909 
.1908 

Italy    

.1908 

Austria                •  • 

.1907 

Hungaria  

.1909 

Russia           .... 

.1901 

The  comparison  of  the  four  columns  shows  that  the  number  by  which 
the  birth-rate  exceeds  the  death-rate  per  thousand  inhabitants  is  quite 
variable  ranging  between  0.3  in  France  to  18.5  in  Russia.  Germany  has  an 
excess  birth-rate  of  13.8  which  is  exceeded  not  only  by  Russia,  but  also  by 
Holland  and  Denmark.  Most  of  the  other  civilized  countries  have  the 
same  number  of  excess  births  as  Germany. 

In  Table  I.  it  can  readily  be  seen  that  a  growth  in  population  can  take 
place  in  two  ways.  First,  by  a  birth-rate  so  large  that  even  after  deducting 
a  large  death-rate  we  have  an  excess;  second,  by  a  lowered  mortality  rate 
such  that  even  a  small  birth-rate  would  give  an  increase  in  the  population. 
Russia  is  an  example  of  the  first  instance;  the  Northern  European  countries 
of  the  second. 
86 


MORTALITY  AND  MORBIDITY 


87 


Each  people  pursue  their  own  course  in  this  matter  depending  upon 
their  many  circumstances.  The  second  way  seems  at  first  glance  to  be  the 
most  rational,  but  the  experience  of  the  civilized  people  seems  to  show  that 
not  only  is  it  very  difficult  to  reduce  the  death-rate,  but  that  a  decrease  in 
the  number  of  births  due  to  prevention  of  conception  is,  in  itself,  a  sign 


TABLE  II.     (GERMAN  EMPIRE.) 
To  Each  1000  Inhabitants. 


Year 

Were  Born  Alive 

Deaths  Including 
Still-Births 

Excess  No.  of 
Births  Over 
Deaths 

1901  

35.7 

21.8 

15.1 

1902  

35.1 

20.6 

15.6 

1903  

33.8 

21.1 

13.9 

1904  

34.0 

20.7 

14.5 

1905  

33.0 

208 

13.2 

1906  

33.1 

19.2 

14.9 

1907  

32.3 

19.9 

14.2 

1908  

32.1 

19.0 

14.0 

1909  

31.0 

18.1 

13.9 

1910  

29.8 

17  1 

136 

1911.               

28.6 

182 

11  3 

1912  

28.3 

16.4 

12.7 

1913  

27.5 

15.8 

12.4 

of  degeneration.  It  seems,  therefore,  that  when  we  try  to  understand  what 
would  be  rational  sex  life  in  the  peoples  of  all  classes  in  the  various  nations, 
there  is  no  safe  means  by  which  to  stop  the  growth  of  a  people.  Unfortu- 
nately even  in  Germany,  which  up  to  the  beginning  of  the  World  War  had 
a  greater  birth  excess  than  most  civilized  countries,  there  has  been  a  defi- 
nite tendency  to  a  decrease  in  the  birth  excess. 

Table  II.  shows  not  only  what  was  pointed  out  in  Table  I.,  namely  the 

TABLE  III. 


Deaths  in  1st  Year  Not 

Deaths  Per  100  Born 

Births  Not 

Deaths  Not 

Illegitimate 
Births  In- 

Including Still-Births 

Alive 

Yrs. 

Still-Births 

Still-Births 

cluding 
Still-Births 

Legitimate 

Illegit. 

Totals 

Aver- 
age 

Legit- 
imate 

Illegit. 

2,032,313 

1,174,489 

179,683 

361,745 

58,478 

420,223 

20.7 

19.4 

33.9 

1901 

2,022,477 

1,112,202 

177,060 

324,592 

50,044 

374,636 

18.5 

17.5 

29.4 

1906 

1,924,778 

1,045,665 

179,584 

267,171 

44,291 

311,462 

16.2 

15.2 

25.7 

1910 

1,838,750 

1,004,950 

183,977 

235,272 

41,924 

277,196 

15.1 

13.5 

21.8 

1913 

great  influence  of  infant  mortality  on  the  general  mortality  rates,  but 
teaches  us  above  all.  the  fact  that  since  about  the  year  1900,  the  number  of 
births  have  decreased  more  rapidly  than  the  number  of  deaths;  also,  that  if 
there  is  further  decrease  in  frequency  of  births,  Germany  will  soon  present 
a  condition  like  that  of  France. 

Table  III.  shows  for  the  German  Empire  the  exact  number  of  those 
living,  those  born  and  those  that  die  in  a  population  of  over  sixty  million. 


88 


TEXT-BOOK  OF  PEDIATRICS 


Also,  the  unfavorable  position  of  the  illegitimate  child,  the  cause  of  which 
will  be  elucidated  further  on. 

As  has  already  been  mentioned,  the  danger  to  life  is  not  the  same  at  all 
times  during  childhood  but  by  far  the  greatest  in  the  first  year  and  propor- 

TABLE  IV. 
Deaths  according  to  age  per  1000  deaths  (in  German  Empire). 


Between 
ages  of 

0-1  yr  

In  the  Year 
1911 

.  ..    317.1 

In  the  Year 
1913 

275.1 

1-2  vr.  .  . 

.  .  .     48.81 

45.1] 

2-3  yr.  .  . 

17.0L,  K 

16.0Un  o 

3-4  yr  

10?84.5 

10.4  79'3 

4—5  yr. 

7.9 

7.8J 

5-6  yr  

.  .  .       6.0) 

6.1 

6-7  yr.   ... 

4.9 

5.1 

7-8  yr.     . 

4.0[21.6 

4.2  22.1 

8-9  yr  

...       3.4 

3.5 

9-10  vr.  .  . 

3.2 

3.0 

Between 


In  the  Year        In  the  Year 


ages  of  1911  1913 

10-1  lyrs 2.8  2.9) 

11-12  yrs 2.8  2.7 


12-13  yrs 2.4 

13-14  yrs 2.7 

14-15  yrs 3.0 


13.9  2.7 
2.7 
2.9 


14.0 


tionately  great,  during  the  second  year.    From  then  on  the  mortality  curve 
sinks  rapidly. 

In  Table  IV.  the  author  has  purposely  contrasted  the  years  1911  and 
1913,  one  a  very  warm,  the  other  a  very  cool  year.   It  can  be  seen  by  noticing 

TABLE  V. 

Number  of  deaths  per  1000  at  various  times  according  to  mortality  tables  for  years  1901  to  1908. 

Still  births       33.47  Previous  mo.     165.53  Previous  mo.     219.39 

1st.  mo.       59.07  5th.  mo.       18.39  9th.  mo.        8.53 

2nd.  mo.       26.77  6th.  mo.       13.73  10th.  mo.         7.41 

3rd.  mo.       25.55  7th.  mo.       12.31  llth.  mo.         5.79 

4th.  mo.       20.67  8th.  mo.         9.43  12th.  mo.         5.45 


Total 


165.53 


Total 


219.39 


Total 


246.57 


the  five  year  periods  as  well  as  the  single  years,  that  a  difference  exists 
mainly  in  the  first  and  to  a  lesser  extent  in  the  second  year. 

The  infant  mortality  is  not  uniform  during  the  first  year  but  is  the 
greatest  during  the  first  part  of  infancy.  This  fact  is  shown  by  a  large 
number  of  statistics,  and  in  Table  V.  by  the  Magdeburg  Statistics. 

During  1918  there  were  193,855  deaths  of  infants  under  one  year  of  age 
in  the  registration  area  of  the  United  States.  They  were  distributed 
through  the  year  as  follows :  Number  Percentage 

Death  occurring  at  of  Deaths.  of  deaths. 

Less  than  1  day 29,106  15 

1st  day 9,554  4.9 

2nd  day   6,829  3.6 

3rd  to  6th  day 12,645  6.5 

Less  than  1  week   58,134  30 

1st  week          11,750  6 

2nd  week     8,292  4.25 

3  weeks  but  less  than  1  month 6,572  3.39 

Less  than  one  month 84,748  43.64 

1st  month 16,278  8.39 

2nd  month 13,238  6.8 

3rd  to  5th  month     31,503  16.25 

6th  to  8th  month  26,111  13.66 

9th  to  llth  month     21,977  11.26 


MORTALITY  AND  MORBIDITY 


89 


Within  the  first  month, 
which  is  the  most  critical 
one  as  far  as  the  life  of 
an  infant  is  concerned,  we 
note  that  the  first  day  and 
week  are  of  greatest  im- 
portance. For  example, 
according  to  carefully  col- 
lected statistics  in  Berlin, 
there  are  two  and  one-half 
times  as  many  deaths  in 
the  first  week,  as  in  the 
second  week  of  life  and 
one-half  as  many  deaths 
during  the  last  half  of  the 
first  month,  as  during  the 
first  two  weeks. 

Two  other  definite  fac- 
tors are  to  be  noted  in  the 
statistics  given  thus  far, 
namely  the  very  much 
higher  mortality  of  the 
illegitimate  as  compared 
to  the  legitimate  child  in 
the  first  year  (Tables  III 
and  IV)  and  secondly,  the 
rise  in  infant  mortality 
in  the  summer  months 
(Table  VIII). 

Many  of  the  diverse 
factors  influencing  the  ex- 
pectation of  life  in  infants, 
which  a  physician  meets 
in  daily  routine  but  has 
not  learned  how  to  eval- 
uate, can  only  be  expressed 
truthfully  if  the  statisti- 
cian is  allowed  absolute 
liberty  in  choice  of  mate- 
rial. This  is  possible,  how- 
ever, in  only  more  or  less 
limited  way  and  for  only  a 
short  space  of  time. 

The  high  mortality  of 
infants  is,  according  to  Malthus,  a  natural  protection  against  an  excessive 
increase  in  population  so  that  individuals  may  be  enabled  to  obtain  the 
necessities  for  life.  Later  under  the  influence  of  the  Darwinian  theories 


Civile  > 

Japan        .    ) 
6c.Tma*.«f            > 
Fra-nct,               } 

VNITEO  STATES             > 

/ 

300 

{            H  u.w.q  a  ry 

^___Oustrl«, 

(            Spain, 
«  Italy 

^  Finland. 

/                 <?<.««il/HL4. 

L1S~~ 

Z50 

2.2.S 

ZOO 

as 

iso 

\ts 

— 

too 

— 

E-nglaud  and  WoUi             y 
1  relaud,               y 
SWed«Tv,          ,      ;> 

tlofwcty                y 

NEW  ZEALAND  > 

75 

— 

^  Netkerlatid* 
^  SiaV.tierLaK.dk 

SO 

— 

{            OLuttraUaj 

z.s~ 

— 

0 

— 

Fia.  20. — Deaths  under  1  year  of  age  per  1000  births.  Rates 
are  for  latest  available  years  up  to  1918  as  compiled  by  the  Chil- 
dren's Bureau,  U.  S.  Dept.  of  Labor.  Within  the  first  year  after 
birth  the  U.  S.  loses  1  in  10  of  all  babies  born.  It  rauks  1 1th 
among  the  principal  countries  of  the  world.  New  Zealand  loses 
fewer  babies  than  any  other  country. 


90 


TEXT-BOOK  OF  PEDIATRICS 


this  was  explained  on  the  basis  of  natural  selection.  Thus  only  the  strong 
survive,  the  weaker,  being  worthless  to  the  race,  are  cast  out.  Many 
statistically  established  facts,  as  for  example,  the  infant  mortality  among 
the  different  classes  of  people  (which  is  firmly  established  and  noticeable 
in  the  German  Empire)  have  been  quoted  as  proof  of  the  Darwinian  Theory 
by  its  supporters.  As  also,  the  higher  mortality  of  the  illegitimates.  HOW- 
TABLE  VI. 

Infant  Mortality  in  Berlin  1900  to  1902. 
IN  FAMILIES  OF  Per  cent. 

1.  Officers,  officials  and  professional  men 11 

2.  Business  men 15 

3.  Skilled  artisans 16 

4.  Unskilled  laborers 18 

ever,  any  one  who  will  look  at  the  facts  as  a  true  physician  and  scientist, 
will  soon  see  that  the  explanation  is  not  to  be  made  on  biological  grounds 
but  on  the  basis  of  social  status.  Much  more  important  is  the  effect  of 
the  social  conditions  under  which  the  child  is  born  and  those  under  which 
he  develops,  as  for  example,  the  financial  condition  of  the  parents.  Accord- 
ing to  statistics,  if  we  choose  the  calling  of  the  parents  or  the  size  of  dwelling 

TAELE  VII. 
Nutrition  and  Infant  Mortality  in  Berlin.     Deaths,  per  1000  infants. 


Breast-ted 

, 

\rtificially-fec 

1885-86 

1895-90 

190C 

1885-86 

1895-96 

1906 

1  

22.4 

19.6 

22.4 

142.0 

111.9 

58.1 

2  

9. 

7.3 

7.9 

82.7 

58.7 

31.3 

3      

6.8 

4.3 

4.3 

72.2 

49.7 

27.3 

4       

6.4 

3.6 

2.4 

61.8 

46.6 

22.1 

5      

5.3 

2.6 

1.7 

57.1 

37.0 

18.5 

6  

4.9 

2.5 

2.2 

50.7 

31.0 

16.1 

7  

4.7 

2.5 

1.4 

46.5 

27.7 

14.1 

8      

4.5 

2.3 

1.8 

40.8 

24.1 

12.2 

9      

5.3 

2.0 

2.1 

33.3 

21.3 

10.2 

10  

5.4 

3.8 

1.5 

29.5 

19.1 

9.2 

11  

6.3 

3.1 

1.3 

24.9 

16.7 

8.0 

12 

3  6 

1  5 

14  6 

8  0 

Average  per  rr.o. 

8.4 

6.0 

6.3 

54.1 

35.8 

23.6 

as  an  indication  of  social  status,  \ve  can  see  the  increased  danger  of  life  to 
infants  born  in  unfavorable  surroundings. 

A  fundamental  law,  substantiated  not  only  in  every  day  medical  prac- 
tice but  also  by  a  large  number  of  statistics,  is  the  high  mortality  of  the  arti- 
ficially-fed as  compared  to  the  low  mortality  of  the  breast-fed  infant.  This 
fact  does  not  coincide  with  the  idea  of  natural  selection.  If  it  were  true 
that  children  do  wrell  only  when  nursed  by  their  own  mothers  we  could  say 
that  the  nursing  ability  of  the  mother  would  give  us  prognostic  knowledge 
as  to  health  of  the  child.  But  we  know  that  children  do  well  on  breast-milk 


MORTALITY  AND  MORBIDITY 


91 


of  other  women  beside  their  mother,  and  also  that  observation  has  firmly 
established  the  fact  that  children  that  are  ill  and  on  artificial  food  recover 
most  rapidly  on  breast-milk.  Thus  even  though  a  very  small  per  cent, 
of  breast-fed  children  may  not  do  well  on  the  breast,  we  should  notice 
more  particularly  the  problem  of  nutrition  rather  than  that  of  hereditary 
defects,  thus  keeping  down  the  infant  mortality  and  assuring  good  health 
to  most  infants. 

The  infant  mortality  rate  in  many  of  the  cities  of  the  United  States  has 
been  reduced  much  below  the  average,  due  to  the  intensive  Infant  Welfare 
work  done  through  many  agencies  and  especially  through  breast  feeding 
propaganda.  The  American  Child  Hygiene  Association  is  the  leading 
National  agency  working  for  the  reduction  of  Infant  Mortality. 

The  figures  for  the  ten  largest  American  cities  taken  from  publication  of 
American  Child  Hygiene  Association  is  given  below. 


1916 

1917 

1918 

1919 

New  York          

93 

89 

92 

82 

Philadelphia       

105 

108 

124 

90 

Detroit           .                           

112 

103 

101    ' 

97 

Cleveland 

109 

109 

98 

91 

St.  Louis  .        

89 

85 

93 

75 

Boston  

105 

99 

115 

97 

Baltimore   •.  

122 

118 

149 

97 

Pittsburgh      •.  

115 

120 

139 

115 

Los  Angeles       

69 

71 

77 

67 

San  Francisco 

67 

63 

67 

65 

The  following  table  shows  the  lowest  and  highest  infant  mortality 
rates  in  cities  of  various  sizes  in  the  United  States  as  published  by  the 
American  Child  Hygiene  Association,  1920. 

CITIES  WITH  HIGHEST  AND  LOWEST  RATES 

Population  over  250,000 
Lowest  Highest 

Seattle,  Wash 54  Pittsburgh,  Pa 115 

Minneapolis,  Minn 61  Buffalo,  N.  Y 107 

San  Francisco 65  Kansas  City,  Mo 103 

Population  100,000-250,000 

Lowest  Highest 

Houston,  Tex 61  New  Bedford 124 

Oakland,  Calif 62  Camden,  N.  J 121 

Cambridge,  Mass 64  Nashville  116 

Population  50,000-100,000 

Lowest  Highest 

Berkeley,  Calif 44  El  Paso,  Tex 245 

Fort  Wayne,  Ind 51  Knoxville,  Tenn 135 

Topeka,  Kan 59  Racine,  Wis 123 

Population  under  50,000 
Lowept  Highest 

Brookline,  Mass 40  Burlington,  Vt 150 

Marinette,  Wis 45  Paducah,  Ky 146 

Aberdeen,  Wash 45  Hannibal,  Mo 145 


92 


TEXT-BOOK  OF  PEDIATRICS 


Aside  from  the  evidence  given  by  statistics  that  the  breast-fed  infant 
has  a  lower  mortality  and  morbidity  rate,  statistics  can  be  adduced  to  show 
the  increased  mortality  as  resulting  from  variations  of  temperature.  In 
Table  VIII. ,  the  years  1911  and  1913  were  chosen  because  the  summer 
months  in  the  latter  were  not  excessively  hot  while  in  the  former  there 
was  persistent  high  temperatures  during  the  months  of  July,  August 
and  September. 

TABLE  VIII. 
Deaths  in  infants  during  first  year  of  life. 


1911  1913 

January 20.99  21.50 

February 22.60  22.83 

March  21.04  24.84 

April 25.04  20.99 

May 25.37  23.33 

June..                          ..27.08  24.52 


1911  1913 

July 49.38  27.41 

August  62.11  27.36 

September 45.04  29.15 

October 23.36  26.01 

November  18.28  25.08 

December 21.71  17.60 


The  editors  add  here  a  table  by  Graham  consisting  of  statistics  from 
the  city  of  Philadelphia  showing  again  the  increased  mortality  in  infants 
on  artificial  foods.  This  table  further  brings  out  the  increased  mortality 
coincident  with  the  summer  heat. 


Breast-fed 

Artificially-fed 

Feeding  not  known 

January          

8 

21 

9 

February  

9 

14 

18 

March            •»                          ... 

13 

15 

21 

April  

9 

13 

17 

May  

10 

16 

27 

June  

7 

4 

50 

July  

8 

155 

138 

August           

28 

148 

161 

September  

22 

104 

71 

October  

18 

56 

73 

November          

11 

36 

36 

December          

10 

24 

34 

153 

606 

655 

Of  the  759  deaths  with  known  type  of  feeding,  20  per  cent,  were  breast-fed 
and  80  per  cent,  were  artificially-fed.  This  is  a  strong  appeal  for  maternal 
nursing.  Maternal  nursing  is  considerably  reduced  because  of  the  very 
high  maternal  mortality  rate  prevailing  in  the  United  States.  According 
to  the  Children's  Bureau  the  United  States  lost  over  23,000  women  in 
1918  from  Childbirth.  We  have  a  higher  maternal  mortality  rate  than  any 
other  of  the  principal  countries. 

In  the  United  States  the  deaths  from  diarrhoea  and  enteritis  under  2  years 
of  age  increase  greatly  during  the  summer  months.  The  total  deaths  (47,- 
753)  from  these  causes  in  1918  is  divided  among  the  months  as  follows: 


January 1775 

February 1712 

March 2040 

April 2192 


May 2712 

June 4027 

July 6811 

August 9822 


September 8128 

October 4458 

November 2394 

December  .  . .  1682 


MORTALITY  AND  MORBIDITY 


93 


Broncho-pneumonia  which  occurs  more  often  in  children  has  a  much 
higher  death-rate  in  the  colder  months.  The  54,697  deaths  from  broncho- 
pneumonia  in  1918  were  divided  among  the  various  months  as  follows: 


September 1853 

October 13078* 

November 6208 

December 5883 


January 5256  May 3005 

February 4901  June 1507 

March 5515  July 1309 

April 5194  August 988 

*  During  influenza  epidemic. 

The  following  circumstances  acting  together  influence  the  mortality 
rate  of  infants  namely,  financial  and  social  status  of  the  parents,  the 
character  of  their  dwelling  place,  the  kind  of  nourishment,  and  also  the 
tune  of  the  year,  but,  the  most  striking  factor  is  the  kind  of  nourishment. 
H.  Neuman  's  statistics  of  Berlin  are  of  interest. 

TABLE  IX. 
Deaths  per  100  children  according  to  housing  conditions. 


1-2  rooms  and 
kitchen 
Percentage 

3  rooms  and 
kitchen 
Percentage 

4  rooms  and 
kitchen 
Percentage 

Total  

17.7 

12.8 

7.3 

Bottle-fed  '  

12.8 

10.9 

4.7 

Breast-fed  

4.9 

2.6 

2.6 

Besides  the  factors  mentioned  above,  others  worthy  of  mention  but 
closely  related  are,  the  unfavorable  prognosis  for  the  illegitimate  child 
because  of  the  lack  of  breast-milk  and  a  mother's  care  and  the  influence  of  a 
large  or  small  number  of  children  in  individual  families. 

Statistics  covering  illegitimacy  in  the  United  States  are  meagre.  The 
latest  authoritative  statement  is  from  the  Eighth  Annual  Report  of  the 
Children's  Bureau  1920.  Miss  Lothrop  states  that,  "Each  year  in  the 
United  States  at  least  32,000  white  children  are  born  out  of  wedlock." 
This  is  proportionately  fewer  than  in  most  foreign  countries.  The  death- 
rate  of  illegitimate  birth,  according  to  the  studies  made  by  the  bureau,  is 
three  times  as  high  as  that  of  other  children. 

The  above  statistics  cannot  be  discussed  fully,  except  that  a  lesson  is 
given  in  the  realm  of  Pediatrics  which  is  familiar  to  all  physicians  who 
understand  social  conditions,  namely,  that  families  in  which  the  children 
are  breast-fed  and  in  which  there  is  a  pause  of  one  and  one-half  to  two  years 
between  children  have  a  minimum  infant  mortality  and  that  the  later 
children  do  not  labor  under  any  disadvantage — (especially  when  we  have 
large  families  of  eight,  ten  or  more). 

In  order  to  understand  the  above  mentioned  facts  a  knowledge  of  the 
causes  of  death  and  the  proportion  of  each  is  necessary.  However,  it  is 
with  reluctance  that  one  presents  statistics  of  the  causes  of  death,  even 
though  there  are  a  great  number  available,  both  of  the  civilized  countries 
and  great  urban  communities  The  value  of  statistics  is  depreciated  be- 
cause of  poor  raw  material  on  which  they  are  based,  giving  conclusions  at 
variance  with  the  facts  noticed  by  the  physician  in  every  day  medical 


94  TEXT-BOOK  OF  PEDIATRICS 

practice.  All  these  statistics  agree,  however,  that  gastrointestinal  disease 
causes  one-third  or  more  of  the  deaths  in  the  first  year  and  that  during  this 
same  time  the  acute  infections  and  inflammation  of  the  respiratory  tract 
cause  but  a  small  part  of  the  total  number  of  deaths.  This  great  number  of 
gastro-intestinal  infections  tells  only  half  the  truth,  because  there  are  many 
indefinite  diagnoses  made,  in  which  the  artificial  feeding  was  the  principal 
fault.  Thus  the  diagnosis  of  congenital  weakness,  debility,  etc.,  have 
been  shown  many  times  to  be  clinically  only  the  manifestation  of  artificial 
feeding.  Even  congenital  lues  which  is  given  as  a  cause  of  death,  very 
often  means  that  death  was  due  to  artificial  feeding  because  many  luetic 
infants  gain  well  on  the  breast.  Again  the  cause  of  death  may  be  ascribed 
to  pneumonia,  furunculosis  or  heart  lesions,  all  of  .which  are  but  terminal 
affairs  following  severe  nutritional  disturbances. 

Close  examination  of  the  high  death-rate  in  summer,  with  due  consid- 
eration of  the  mode  of  feeding,  reveals  the  fact  that  only  the  partially  or 
entirely  artificially-fed  infants  contribute  to  the  increased  death-rate. 

The  possible  explanations  of  this  fact  are  given  in  detail  in  the  Chapter 
on  The  Disturbances  of  Nutrition  in  Infants. 

All  the  injuries  of  artificial  feeding  react  most  severely  upon  the  children 
of  the  poorer  classes.  H.  Neumann  says,  as  a  result  of  his  experiences  in 
Berlin,  "The  results  of  natural  feeding  are  very  good  in  the  various  strata 
of  society.  In  artificial  feeding  the  expectation  of  life  is  reduced  in  pro- 
portion to  the  level  of  the  social  stratum."  Special  proof  of  this  general 
rule  is  seen  in  the  high  mortality  of  illegitimate  infants. 

The  death-rate  decreases  markedly  from  the  second  year  and  this  is 
probably  due  to  the  fact  that  after  the  second  year  disturbances  of  nutri- 
tion, as  a  cause  of  death,  become  more  and  more  uncommon.  In  their 
place,  however,  the  acute  exanthemata,  diphtheria  and  tuberculosis  appear 
more  frequently. 

Even  though  vital  statistics  give  us  exact  information  as  to  mortality 
in  its  many  sided  relationship  to  age,  season,  social  welfare,  methods  of 
feeding,  etc.,  it  is  impossible  for  obvious  reasons  to  draw  from  them  even  an 
approximate  picture  of  the  morbidity. 

The  statistician  obtains  reliable  figures  for  only  one  group  of  diseases — 
the  acute  infections  of  childhood  which  must  be  reported  to  the  health 
authorities,  and  then,  of  course,  only  of  those  cases  which  are  seen  by  a 
physician.  In  some  classes  of  society  and  in  some  parts  of  the  country, 
this  is  only  a  negligible  number.  All  the  statistics  based  upon  the  material 
of  various  dispensaries  and  clinics  suffer  from  similar  errors  and,  therefore, 
we  forego  citing  any  of  them. 

All  these  arduous  compilations,  among  which  the  work  of  Escherich 
must,  at  least,  be  mentioned,  have  so  far  succeeded  only  in  proving  -to 
every  observing  physician  the  fact  that  every  period  of  childhood  has  its 
peculiar  disease  groups,  which  are  notable  for  their  frequency,  rarity,  or 
complete  absence ;  or  for  the  definite  combinations  they  present  of  seemingly 
unconnected  disorders  and  anomalies  which  indicate  close  pathogenetic 
relationships  between  them.  It  would  not  seem  that  the  time  has  arrived 


MORTALITY  AND  MORBIDITY  95 

when  a  general  pathology  of  the  diseases  of  childhood  may  be  written,  since 
pediatrics  is  still  a  young  science  and  must  concern  itself  for  a  long  time 
with  the  collection  of  data.  But  the  attempt  to  examine  the  disease  groups 
of  the  various  stages  of  development  more  closely  and  to  draw  briefly  such 
conclusions  as  appear,  after  careful  study,  to  have  a  basis  in  fact,  is  justified. 
These,  however,  are  very  few  if  one  does  not  wish  to  enter  deeply  into  the 
etiology  of  the  various  diseases;  a  topic  for  which  the  reader  is  referred  to 
the  literature  at  large. 

These  factors  are  especially  concerned  in  the  startlingly  high  morbidity 
which  is  revealed  by  the  enormous  mortality  of  the  first  few  days  of  life. 
They  are:  (1)  Congenital  Malformations,  in  so  far,  as  they  affect  extra- 
uterine  life ;  (2)  Birth  Injuries,  and  (3)  -Congenital  Debility. 

The  first  group  is  probably  the  least  important,  while  birth  injuries  are 
frequently  the  cause  of  more  or  less  serious  illness,  which  often  results  in  the 
death  of  the  child.  Omitting  the  danger  of  infection  from  the  birth  canal, 
hemorrhages  from  vital  organs  (the  central  nervous  system  and  its  cover- 
ings, the  adrenals,  etc.),  either  as  a  result  of  congestion  or  injury  following 
the  use  of  force  in  difficult  labor,  are  apparently  common  to  both  of  the 
first  two  groups. 

Congenital  debility  is  not  confined  to  premature  infants  alone,  although 
it  is  much  more  common  among  them  than  in  others.  Under  congenital 
debility  is  included  functionally  retarded  development  of  a  degree  which 
imperils  the  life  or  development  from  birth,  even  though  it  be  given  the 
same  care,  in  the  way  of  suitable  temperature,  breast  feeding  and  freedom 
from  infection,  under  which  children  normally  develop.  Space  will  not 
permit  us  to  enter  into  the  pathology  of  congenital  debility.  We  can  only 
call  attention  to  the  fact  that  its  diagnosis  must  be  confined  to  those  cases 
in  which  an  abnormally  labile  temperature,  a  reduction  of  the  respiratory 
rhythm  and  often  a  marked  disturbance  of  reaction  to  all  physiologic 
stimuli  can  be  shown.  The  early  death  of  a  new-born  infant  as  a  result  of 
artificial  feeding,  or  of  infection  and  the  like,  cannot  be  laid  to  congenital 
debility,  if  we  do  not  wish  to  make  this  diagnosis  the  "catch  all"  of  diag- 
nostic uncertainties  and  imperfect  observations. 

That  the  morbidity  of  infancy  is  governed  by  artificial  or  unnatural 
feeding  cannot  be  repeated  too  often.  The  experience  of  physicians  teaches 
this  incontrovertibly,  and  not  only  that  the  more  or  less  severe  disturbances 
of  nutrition  or  gastro-intestinal  diseases  occur  almost  exclusively  in  arti- 
ficially-fed infants,  but  that  this  is  true  also  of  the  development  and  the 
severity  of  the  numerous  parenteral  infections  of  the  skin,  the  respiratory 
system,  the  uro-genital  tract,  etc. 

As  examples,  which  might  be  multiplied  without  end,  it  suffices  to 
mention  furunculosis  and  numerous  other  purulent  infections  of  the  skin, 
lobular  and  hypostatic  pneumonia,  cystitis  and  pyelonephritis.  The  same 
relationship  appears  in  the  cachectic  types.  Spasmophilia,  the  exudative 
diathesis,  rickets,  etc.,  exhibit  much  more  serious  manifestations  in  the  arti- 
ficially-fed infant  than  in  the  breast-fed  child. 

The  frailty  and  low  resistance  of  the  infant,  as  compared  with  older 


96  TEXT-BOOK  OF  PEDIATRICS 

children,  have  always  been  proper  subjects  of  special  attention.  Emphasis 
should  be  put,  however,  upon  the  fact  that  the  normal  healthy  child  with 
suitable  food  and  care,  beginning  with  a  sufficiently  long  period  of  breast 
feeding,  does  not  exhibit  nearly  so  great  morbidity  as  one  might  be  led  to 
suppose  by  the  high  mortality  statistics. 

Why  artificial  feeding,  even  when  the  weight  curve  shows  that  it  is 
conducted  to  good  results,  should  increase  the  morbidity  of  the  new-born 
and  of  older  infants  so  markedly  and  should  lower  their  immunity  so 
distinctly  has  not  yet  been  determined.  Whether  feeding  with  human  milk 
produces  a  sort  of  passive  immunity  by  the  constant  supply  of  antibodies 
from  the  mother's  milk,  or  whether  the  artificial  food  prejudices  the  chemical 
integrity  and  consequently  the  functional  resistance  of  the  infant  organism, 
are  questions  still  under  discussion,  the  solution  of  which,  however,  will 
not  materially  alter  clinical  methods. 

The  infant  escapes  a  certain  number  of  diseases,  because  even  with  the 
poorest  of  care  he  is  not  exposed  to  certain  of  the  dangerous  injuries  of 
later  life.  Among  these  may  be  mentioned  traumatic  diseases,  the  results 
of  exposure  to  inclement  weather  and,  particularly,  the  lesser  opportunity 
of  contact  with  a  variety  of  infections,  so  long  as  the  child  lies  quietly  in 
his  bed.  After  the  first  year,  in  fact  as  soon  as  the  child  begins  to  creep 
and  comes  more  frequently  into  contact  with  his  surroundings,  all  this 
is  changed. 

Dirt  and  contact  infections,  in  fact,  reach  their  maximum  in  the  second 
and  third  years.  Of  these,  diphtheria,  pertussis,  contagious  impetigo, 
aphthus  stomatitis,  various  forms  of  angina,  and  tuberculosis,  may  be 
mentioned.  Certainly  it  is  not  an  accidental  thing  that  most  of  these 
diseases  have  their  primary  localization  or  rather  their  port  of  entry  in  the 
mucous  membranes  of  the  mouth  and  upper  air  passages,  to  which  the 
grimy  hands  and  unclean  toys  or  eatables  passing  from  floor  to  mouth  first 
bring  their  load  of  disease  germs.  Later  another  opportunity  is  freely 
given  among  the  crowds  of  children  in  the  kindergarten  and  the  schools 
where  they  come  into  contact  with  one  another  in  their  play  at  a  time  when 
the  prodromata  of  the  acute  contagious  exanthemata  may  be  present. 

It  will  be  seen  that  there  are  all-important  external  influences  which 
give  a  peculiar  stamp  to  the  morbidity  of  the  run-about-age  and  of  the 
early  school  years.  Undoubtedly  the  school  age,  when  the  so-called  school 
diseases  appear,  broadens  the  circle  of  infections  which  threaten  the  child. 
At  this  period,  whether  we  have  to  deal  with  such  diseases  as  scoliosis, 
myopia  and  other  visual  disorders,  with  headache,  anorexia,  disturbed  sleep 
and  the  like;  or  with  such  distinct  neuroses  as  hysteria,  migraine,  neuras- 
thenia, psychopathy,  etc.,  it  is  always  possible  to  find  beneath  the  actual 
injury  arising  from  school  attendance,  an  existing  and  recognizable  pre- 
disposition, or  the  influence  of  injuries  traceable  to  home  surroundings  and 
training,  which  have  played  an  important  part. 

As  the  child  approaches  puberty,  the  disease  groups  of  both  sexes  come 
to  resemble  more  and  more  those  of  the  adult.  Early  puberty  shows  a 
slight  increase  of  morbidity  as  compared  with  the  low  morbidity  of  late 


MORTALITY  AND  MORBIDITY  97 

boyhood  and  girlhood.  Aside  from  those  disturbances  which  stand  in 
direct  relationship  to  the  development  of  the  genital  organs,  an  increasing 
frequency  of  tuberculous  manifestations,  of  certain  infections,  of  functional 
heart  diseases  and  psychic  anomalies,  are  especially  to  be  noted.  These 
years  are  characterized,  as  we  have  already  seen,  by  a  marked  increase  in 
the  rapidity  of  growth  in  height  and  by  the  development  of  various  organs 
and  their  systemic  relations. 

The  relational  study  of  the  increased  rate  of  growth  and  the  greater 
morbidity  of  the  years  of  development  has  suggested  the  theory  that  this 
rapid  growth  and  the  more  rapid  metabolism  associated  with  it  serve  to 
increase  the  vulnerability  of  the  tissues  and  organs  to  disease.  The  hypo- 
thesis is  a  very  probable  one  and  affords  a  possible  explanation  of  many 
other  observations;  e.  g.,  to  cite  but  one  instance,  the  localization  of  rachitic 
changes  at  the  epiphyses,  the  point  of  the  entire  bone  of  by  far  the  greatest 
measure  of  growth  (Kassowitz).  Much  is  still  wanting  by  way  of  accept- 
able proof  of  this  hypothesis  to  permit  its  use  even  as  a  working  basis  for 
the  study  of  the  relational  operation  of  these  factors  in  the  living  mechanism. 


V.  GENERAL  PROPHYLAXIS  AND  THERAPY 

REVISED  BY 
ALBERT  H.  BYFIELD,  M.D., 

Professor  of  Pediatrics,  State  University  of  Iowa,  College  of  Medicine,  Iowa  City. 

(a)  GENERAL  PROPHYLAXIS  - 

THE  protection  of  the  child  from  disease  should  begin  before  birth.  The 
influence  the  physician  can  exercise  in  the  prevention  of  congenital  disease 
is  usually  very  slight,  even  in  the  families  of  the  educated  classes;  and 
among  the  uneducated  there  is  a  general  want  of  responsibility  for  their 
progeny.  It  must  be  admitted,  however,  that  rarely  does  the  present  in- 
complete understanding  of  the  laws  of  heredity  permit  prediction,  in  a 
given  case  or  with  any  degree  of  certainty,  of  children  sound  in  mind  and 
body.  Particular  attention  should  be  called  to  the  fact  that  the  marriage  of 
close  relatives  does  not,  in  itself,  endanger  their  offspring,  and  that  ill 
results  are  observed  only  in  cases  of  converging  hereditary  taint  (Feer). 
Thus  the  prenatal  protection  of  the  child  practically  begins  only  after 
conception,  and  then  only  in  so  far  as  instruction  and  circumstances  permit 
the  mother  to  take  such  measures  to  safeguard  her  own  health  as  are 
necessary  to  the  well-being  of  her  expected  child.  This  volume  is  not  the 
place  in  which  such  teaching  may  be  given  in  detail;  Mention  might  be 
made  here  of  the  possible  relationship  between  the  nutrition  of  the  parents 
and  that  of  the  offspring,  such  as  occurs  in  the  animals. 

During  delivery  the  child  is  in  actual  danger  of  injury  by  trauma  and 
from  infection.  Further,  it  may  be  said  that  an  injury  during  birth  or  from 
puerperal  disease  may  so  injure  the  mother  that  nursing  becomes  impos- 
sible and  that  child  loses  the  mother's  care.  It  is,  therefore,  desirable  that 
infant  welfare  organizations  consider  the  hygiene  of  maternity  and  espe- 
cially of  the  puerperium,  as  well  as  the  direct  care  of  the  infant. 

It  has  been  clearly  shown  in  Chapter  IV.,  that  the  greatest  danger 
which  threatens  the  life  and  health  of  the  infant  arises,  directly  or  indi- 
rectly, from  artificial  feeding.  Hence  the  most  important  prophylactic 
measure  is  a  sufficiently  long  period  of  feeding  with  mother 's  milk. 

The  methods  of  breast  feeding,  even  in  cases  where  difficulties  or  dangers 
arise,  are  fully  discussed  in  the  second  chapter.  The  spread  of  the  propa- 
ganda for  breast  feeding  by  institutions  for  infant  welfare  will  be  fully 
described  later. 

The  avoidance  of  infection  is  an  important  feature  of  prophylaxis  even 
in  children.  It  must  begin  in  the  new-born.  Even  though  purulent  infec- 
tions of  the  umbilicus  do  not  have  the  importance  which  was  formerly 
assigned  to  them,  tetanus  of  the  new-born,  which  is  always  avoidable, 
undoubtedly  has  its  origin  in  the  umbilical  wound.  Ophthalmia  neonatorum 
is  equally  preventable  and  it  should  therefore  be  made  the  duty  of  the 


GENERAL  PROPHYLAXIS  AND  THERAPY       99 

physician  and  of  the  midwife  to  use  the  Crede  instillation  in  all  cases  even 
where  gonorrheal  disease  of  the  mother  can  be  absolutely  excluded.  The 
physician  should  be  careful  to  see  that  this  order  is  carried  out. 

The  organisms  of  infection  to  which  the  infant  is  exposed  find  entry 
through  the  mucous  membranes  of  the  upper  air  passages  and  mouth. 
Among  these  infections  we  may  mention  rhinitis,  tonsillitis,  pharyngitis, 
bronchitis  and  influenza. 

Generally  speaking,  all  of  these  diseases  run  a  more  severe  course  in 
young  infants,  and  especially  in  children  artificially-fed  or  suffering  with 
disturbances  of  nutrition.  It  is  therefore  necessary  to  guard  such  children 
against  these  infections  in  every  possible  way.  This  is  measurably  and 
readily  possible  because  these  diseases  are  favored  or  induced  by  climatic 
influences.  Obviously,  this  method  of  contagion  is  not  of  major  importance. 
Usually,  these  infections  are  carried  to  the  child  by  the  adults  of  the  family. 
Therefore,  the  most  effective  measure  would  be  to  keep  persons  suffering 
with  any  of  these  diseases  entirely  away  from  the  child.  This  is  practical 
so  far  as  other  sick  children  of  the  family  are  concerned  and  should  be 
achieved  as  thoroughly  as  the  circumstances  of  the  home  will  permit.  Of 
course  it  is  not  always  possible  to  replace  adults  to  whom  the  care  of  the 
infant  is  entrusted.  Nevertheless,  the  danger  of  the  spread  of  contagion 
by  adults  may  be  definitely  reduced  by  proper  precautions  prescribed  by 
the  physician.  Since  the  infection  in  the  above  diseases  is  spread  either  by 
the  hands  of  affected  persons  soiled  with  infectious  material  or  by  particles 
sprayed  into  the  air,  not  only  by  coughing  and  sneezing,  but  even  by 
speaking,  laughing,  etc.,  it  may  be  avoided  by  the  exercise  of  due  care. 
This,  of  course,  implies  that  infected  material  must  be  kept  not  only  from 
the  child's  person,  but  also  from  all  such  objects  as  clothing,  pacifiers, 
etc.,  with  which  the  child  comes  in  contact. 

In  normal  children  the  predisposition  to  this  group  of  diseases  tends  to 
diminish  with  increasing  age ;  so  that  we  may  fairly  say  that  children  who 
are  infected  every  time  they  come  in  contact  with  an  adult  suffering  from 
any  of  these  respiratory  disorders  have  a  pathologic  predisposition  or  are 
so-called  susceptible  children.  This  class  will  be  more  fully  discussed  later. 

Even  with  careful  training  the  majority  of  children  do  not  learn  to  use 
mouth-washes  and  gargles  correctly  before  the  fourth  or  fifth  year.  The 
most  important  prophylactic  measure  against  infection  is,  therefore,  to 
keep  children  away  from  any  source  of  trouble.  To  carry  out  this  measure 
successfully  it  will  be  found  necessary  to  accustom  the  child,  even  when 
well,  to  refrain  from  unnecessary  caresses  and  the  like. 

All  this  is  equally  true  of  the  so-called  diseases  of  childhood;  the  acute 
exanthemata,  diphtheria  and  pertussis.  These  diseases,  likewise  are 
transferred  only  by  close  contact  with  those  suffering  with  them  or  by 
contamination  from  their  secretions.  Since,  with  the  exception  of  diph- 
theria, one  attack  usually  confers  immunity,  it  is  readily  seen  that  adults 
spread  infection  only  as  carriers  and  that  the  greatest  danger  to  the  child 
lies  in  contact  with  diseased  children.  Day  nurseries,  kindergartens  and 
schools  offer  the  most  frequent  opportunities  for  contagion.  The  spread  of 


100  TEXT-BOOK  OF  PEDIATRICS 

measles  and  pertussis  is  increased  by  the  fact  that  these  diseases  are  con- 
tagious in  their  prodromal  stages.  Danger  in  diphtheria  lies  in  the  fact 
that  in  many  cases  there  are  no  characteristic  symptoms.  It  is  the  duty, 
therefore,  of  parents,  a  duty  which  the  physician  should  impress  upon  them, 
to  keep  children  at  home  when  they  are  ill  or  even  under  suspicion  of  disease 
in  order  to  protect  their  playmates  and  school  fellows.1 

If  any  such  disease  makes  its  appearance  in  a  family  in  which  all  of  the 
children  are  not  immunized  by  previous  attacks,  every  possible  precaution, 
of  course,  must  be  taken  by  the  complete  isolation  of  the  patient,  and  this 
isolation  should  extend  to  the  objects  used  by  him  and  should  include 
adults  who  nurse  him.  Under  such  circumstances  infection  is  carried 
much  more  readily  by  the  adult  because  of  the  frequency  of  exposure,  than 
it  is  if  contact  is  only  occasional  and  for  a  brief  period.  For  this  reason,  the 
physician  is  less  often  a  carrier  than  the  mother.  When  the  question  arises 
of  removing  other  children  from  the  home  to  place  them  in  the  care  of 
relatives,  we  must  consider  not  only  any  obstacles  which  may  exist  to  their 
effective  care  and  isolation  in  a  new  abode,  but  also  the  possibility  that 
they  themselves  are  in  the  incubation  period  of  the  disease.  It  is  always 
best  to  keep  such  children  away  from  other  families  where  there  are  children 
who  might  be  endangered  by  exposure  to  disease.  As  it  is  practically 
impossible  to  guard  children,  in  a  large  city,  at  least,  from  the  acute  exan- 
themata, it  may  be  as  well  to  resort  to  extreme  prophylactic  measures 
only  for  those  whose  health  would  be  especially  jeopardized  as  a  reason  of 
their  age  or  because  of  latent  tuberculous  foci  (or  other  influences  tending 
to  lower  resistance). 

A  peculiar  method  of  disease  conveyance  is  exemplified  in  the  so-called 
dirt  infections  which  are  most  common  during  the  second  and  third  years. 
Children  creeping  about  the  floor  and  putting  soiled  toys  and  dirty  hands 
in  their  mouths,  may  contract  diphtheria,  pertussis,  impetigo,  aphthous 
stomatitis,  angina,  and  occasionally  tuberculosis,  in  this  way.  The  only 
means  of  combating  this  mode  of  infection  is  by  training  the  child  and, 
while  the  child  is  still  too  young  for  this,  by  the  most  scrupulous  cleanliness  of 
the  room,  toys,  and  utensils.  This  may  be  accomplished  most  successfully 
by  the  use  of  pen  shown  in  Fig.  10. 

The  prevention  of  tuberculosis  during  childhood  is  largely  a  question  of 
a  sanitary  home  and  the  proper  hygienic  care  of  the  child  and  of  tubercu- 
lous adults  with  whom  the  child  comes  in  contact.  Since  this  can  be  but 
partially  achieved  in  a  large  population  and  then  only  with  considerable 
difficulty,  the  most  reliable  method  of  prophylaxis  lies  in  the  absolute 
isolation  of  the  tuberculous  member  of  the  family.  This  is  best  accom- 
plished by  placing  the  infected  individual  in  a  sanatorium.  If  this  is  not 
possible  and  if  the  hygienic  conditions  in  the  home  are  not  good,  the  danger 
of  contagion  is  very  great,  as  is  evidenced  by  the  high  incidence  of  the 
infection  in  the  children  of  the  proletariat  of  the  larger  cities.  The  danger 
of  tuberculosis  for  the  child  in  the  school  is  but  slight.  The  experience  of 

1  The  problem  of  diphtheria  carriers  and  the  detection  of  them  is  more  fully  dis- 
cussed under  "Diphtheria"  in  the  chapter  on  Infectious  Diseases. 


GENERAL  PROPHYLAXIS  AND  THERAPY  101 

school  physicians  has  shown  that  the  number  of  children  of  school  age  with 
open  tuberculosis  is  extremely  small.  The  danger  that  the  teacher  may  be 
the  source  of  infection  must  be  considered  as  much  more  likely.  It  should 
be  remembered,  furthermore,  that  the  danger  of  infection  comes  not  alone 
from  members  of  the  immediate  family,  but  also  from  such  other  residents 
in  the  house  as  servants,  governesses,  tutors,  lodgers,  etc.  The  necessity  of 
a  more  careful  survey  of  the  health  control  of  these  people  than  is  usually 
made  will  be  readily  recognized.  Parents  have  been  known  to  actually 
take  their  children  to  visit  friends  or  relatives  suffering  with  advanced 
tuberculosis.  It  is  equally  evident  that  healthy  children  may  be  infected 
with  syphilis  by  a  luetic  wet-nurse  or  any  other  servant,  a  danger  to  be 
safeguarded  by  careful  medical  examination  of  those  employed. 

Besides  these  prophylactic  measures,  the  lessening  of  the  predisposition 
to  disease  by  improvement  of  the  general  constitutional  resistance  offers 
the  largest  possibility  of  success.  As  already  shown,  children  are  not  alike 
in  their  susceptibility  either  to  tuberculosis  or  to  the  ordinary  diseases 
which  arise  from  common  "colds;"  an  evident  tendency  to  disease  may 
entirely  disappear  in  some  children  during  early  childhood,  whereas  in 
others  it  remains  almost  unchanged  even  through  the  school  age.  These 
latter  not  infrequently  have  parents  who  themselves  as  children  suffered 
with  similar  catarrhal  infection.  It  would  seem  that  this  heightened 
susceptibility  of  children  to  these  respiratory  troubles  can  be  traced  back  to 
some  unusually  severe  or  long  drawn  out  acute  infection  which  occurred 
early  in  the  child 's  life,  which  left  a  locus  minon's  resistentice  which  endures 
for  many  years.  That  chronic  infection  may  reside  in  the  nasal  accessory 
sinuses  seems  to  have  been  established  beyond  question.  In  such  cases  it  is 
necessary  to  try  to  avoid  those  conditions  which  will  stir  up  these  respira- 
tory infections  or  cause  new  ones.  The  method  of  feeding,  plays  a  very 
important  part  even  beyond  infancy.  As  overfeeding  is  a  cause  of  great 
danger  to  the  infant,  so  diets  containing  an  excess  of  protein  or  fat  tend,  in 
children  with  a  special  predisposition  to  catarrh,  to  aggravate  and  to 
lengthen  the  duration  of  the  attacks.  Czerny  has  laid  particular  emphasis 
upon  this  factor,  often  under-estimated  even  by  the  physician,  in  his 
treatise  on  exudative  diathesis.  He  notes  that  such  children  do  best  upon  a 
diet  largely  vegetarian.  [It  should  not  be  forgotten  that  a  sufficient  quantity 
of  milk,  preferably  poor  in  fat  must  be  included  in  order  to  supply  the 
calcium  phosphate  and  other  salts  necessary  for  growth.] 

The  aim  with  such  children  should  be  to  develop  good  resistive  powers 
by  methods  which  need  adaptation  to  the  individual  case.  As  a  result  of 
the  theory  that  most  of  these  catarrhal  conditions  are  the  result  of  "catch- 
ing cold, "  it  has  been  thought  necessary  merely  to  accustom  the  patient  to 
cold  or  rather  to  temperature  changes  and  this  has  led  to  an  unbalanced 
and  excessive  use  of  cold  water  treatment.  We  know  now  that  this  method 
should  be  employed  sparingly  in  susceptible  children,  if  it  is  to  be  useful 
rather  than  harmful,  and  that  any  rapid  cooling  of  the  body-surface  by 
douches,  baths,  cold  sponging,  etc.,  which  is  not  immediately  followed  by  a 
vasomotor  reaction  and  a  feeling  of  warmth,  may  directly  provoke  or 


102  TEXT-BOOK  OF  PEDIATRICS 

aggravate  catarrh  and  may  exercise  a  bad  influence  upon  the  nervous  sys- 
tem. The  child  may  be  hardened  more  safely  and  more  easily  by  accus- 
toming it  to  remain  in  the  open,  even  in  variable  and  cool  weather.  H^ere, 
also,  extreme  and  continued  cooling  of  the  body  is  to  be  prevented  by 
sufficient  clothing  and  exercise.  The  clothing  should  not  be  so  heavy  as  to 
be  impermeable  to  air,  and  the  head  and  neck,  in  particular,  should  be 
covered  but  lightly.  It  is  not  wise  to  send  children  out  to  play  with  bare 
legs  and  in  thin  clothing  in  cold  weather. 

The  unquestionably  favorable  influence  of  fresh  air  depends  not  alone 
upon  the  direct  action  of  the  cold,  but  also  very  largely  upon  the  effect  of 
air  currents  and  the  greater  amount  of  sunlight.  Both  of  these  agencies 
produce  effects  just  opposite  to  that  of  cold,  in  that  they  serve  as  stimuli  to 
the  peripheral  circulation.  A  happy  combination  of  these  factors  is  the 
probable  cause  of  the  favorable  effect  of  sea  air  even  in  children  for  whom 
cold-sea-bathing  should  be  prohibited.  Doubtless,  the  much  greater  out- 
door acti  vity,  the  resultant  muscular  exercise  and  an  increased  metabo- 
lism play  a  combined  part,  scarcely  to  be  over-estimated,  in  this  process 
of  hardening. 

In  exudative  children,  training  plays  an  even  more  important  part  than 
it  does  with  children  in  general;  'because  the  frequent  and  inconsequential 
illnesses  of  these  individuals  may  in  themselves  lead  to  errors  of  manage- 
ment which  in  their  turn  develop  those  neuropathic  tendencies  which  are 
often  latent  in  them.  It  is  absolutely  necessary  that  such  training  should 
be  continuous.  It  is  very  important  that  they  be  not  permitted  to  look 
upon  illness  as  a  pleasant  and  desirable  experience  because  of  the  excessive 
care  and  tenderness  that  are  lavished  upon  them  in  such  events.  Ma- 
lingering to  avoid  school  attendance  and  other  unpleasant  and  even  hys- 
terical manifestations,  may  result  from  grave  errors  in  training.  If  this 
viewpoint  cannot  be  sufficiently  impressed  upon  the  child 's  parents  it  may 
become  necessary  in  extreme  instances  to  advise  a  change  of  environment. 

Not  only  exudative  and  neuropathic  but  rachitic  children  as  well, 
require  special  prophylactic  measures  to  guard  them  against  serious  com- 
plications. Of  these,  scoliosis  is  the  most  important  because  of  the  dif- 
ficulties of  its  later  treatment.  Since  this  condition  is  due  in  the  majority  of 
cases  to  long  continued  and  unchanging  position,  special  emphasis  should 
be  put  upon  the  frequent  shifting  of  position,  carrying  the  infant  first  on 
one  arm  and  then  upon  the  other,  and  supporting  it  so  that  no  bending  of 
the  vertebral  column  can  occur.  For  children  in  their  second  year,  who  are 
accustomed  to  sit  without  support,  the  rocking-chair  designed  by  Epstein 
(Fig.  21)  is  very  useful,  because  it  forces  the  child  to  employ  the  muscles 
of  the  back  to  keep  its  balance  while  rocking  and  by  keeping  the  arms 
high,  to  hold  the  back  straight  while  at  the  same  time  the  weight  of  the 
body  is  taken  from  the  legs — which  may  at  times  be  necessary — and  it 
is  impossible  for  the  child  to  sit  with  them  doubled  under  him.  For  older 
children,  a  rocking-horse  or  a  swing  may  serve  the  same  purpose.  System- 
atic massage  may  be  used  successfully. 

The  child  welfare  movement  is  of  recent  origin  and  has  for  its  purpose  the 


GENERAL  PROPHYLAXIS  AND  THERAPY      103 

prophylactic  protection  of  children.  Interest  in  infant  welfare  has  been 
aroused,  on  the  one  hand,  by  the  well-established  fact  that  infant  morbidity 
and  mortality  did  not  show  the  distinct  decrease  recorded  during  the  last 
few  decades  and,  on  the  other  hand,  by  the  absence,  at  least  in  European 
countries,  of  a  normal  increase  in  population  resultant  upon  the  diminished 
birth  rate.  (See  Chapter  IV.) 

There  are  two  problems,  in  particular,  with  which  infant  welfare  work 
is  chiefly  concerned.  It  has  been  shown  that  the  high  infant  mortality  is 
found  largely  among  the  artificially-fed.  In  the  course  of  the  last  decades 
a  reduction  both  of  the  number  of  nursing  mothers  and  of  the  length  of  the 
nursing  period  has  occurred  almost  everywhere.  This  is  due  not  so  much 
to  a  lessened  interest  in  children  and  their  welfare  as  it  is  to  a  false  estimate, 
among  all  classes  of  the  people,  of  the  effectiveness  of  artificial  feeding  and 
of  the  extent  to  which  it  may  replace 
breast  feeding. 

It  should  not  be  forgotten  that  an 
overvaluation  of  sterilized  infant  foods 
and  the  development  of  a  huge  indus- 
try for  the  manufacture  of  artificial 
foods  (preserved,  sterilized,  and  evap- 
orated milk  and  infant  foods,  flours, 
etc.),  almost  all  of  them  heralded  in 
the  advertisements  as  the  "best"  or 
"perfect  substitute  for  mother's  milk, " 
have  contributed  their  harmful  influ- 
ences in  lessening  breast  feeding. 

Those  artificially-fed  infants  who 
are  denied  not  only  their  natural  food 

,  ,         ,  11  •  rio.  21. — Epstein  s  rocking-chair. 

but  a  mother  s  care  as  well  are  in  great- 
est danger.  The  increased  participation  of  women  in  the  various  industries, 
in  so  far  as  it  leads  to  the  mother's  absence  from  home,  has  developed  a 
serious  menace  which  threatens  the  health  and  life  of  infancy  and  the  nor- 
mal growth  and  training  of  older  children.  Not  only  does  the  alarmingly 
high  mortality  among  infants  and  the  neglect  of  older  children  stand  in 
direct  relation  to  this  great  question,  but  domestic  poverty,  the  abuse  of 
alcohol,  the  development  of  tuberculosis  and  social  evil  in  general  are  closely 
associated  with  the  necessity  of  wage-earning  by  the  mother  with  its  conse- 
quent disruption  of  the  family. 

Accordingly,  the  work  attempted  by  infant  welfare  organizations 
should  include  first  of  all  an  efficient  propaganda  for  breast  feeding  aided  by 
the  teachings  of  physicians  in  private  practice,  free  dispensaries,  the  activ- 
ities of  visiting  nurses  in  the  homes  of  the  people,  the  distribution  of 
pamphlets,  public  lectures,  as  well  as  direct  appeal,  as  for  example,  by  the 
offer  of  prizes  to  nursing  mothers.  It  would  be  well  worth  while  to  offer 
special  training  to  physicians  and  nurses  who  after  all  are  the  most  efficient 
agents  in  this  propaganda  in  order  that  they  may  be  best  fitted  to  carry  out 
their  work  in  this  new  and  special  field  of  social  endeavor. 


104  TEXT-BOOK  OF  PEDIATRICS 

The  second  and,  in  the  interim,  an  equally  important  task  lies  in  the 
improvement  of  the  methods  of  artificial  feeding  or,  at  least,  in  the  decrease 
of  its  dangers.  In  this  matter,  individual  and  popular  teaching  are  little 
less  important  than  the  provision  of  certified,  bacterially  pure  milk  for  the 
poorer  classes,  either  by  milk  laboratories  or  dispensaries,  and  the  improve- 
ment of  the  general  market  supply  of  milk  by  careful  inspection.  The  ad- 
visability of  relying  upon  milk  which  has  not  been  boiled  is  open  to  serious 
question.  The  actual  work  in  this  line  is  the  more  difficult  because  it  must 
be  so  conducted  that  it  will  not  discourage  breast  feeding,  the  attainment 
of  which  alone  will  insure  the  lasting  benefits  of  infant  welfare  work  in  the 
economics  of  the  nation. 

Finally,  the  third  and  most  difficult  task  is  the  expansion  and  regulation 
of  actual  economic  assistance  in  so  far  as  it  leads  to  the  complete  protection 
of  the  infant.  Special  emphasis  must  be  laid  upon  the  fact  that  the  sepa- 
ration of  the  mother  and  infant  must  be  prevented  by  adequate  aid  to  the 
mother  and  that  when  this  is  impossible  the  child  should  be  placed  in  an 
institution  where  it  will  receive  proper  and  continuing  care.  The  law 
fixing  the  responsibility  of  the  father  for  at  least  the  provision  of  food  for 
his  illegitimate  children  has  proved  successful.  Lying-in-hospitals  where  the 
nursing  mother  and  child  are  cared  for  and  housed  for  a  sufficiently  long 
period  serve  beneficently  the  welfare  of  both.  Physicians  experienced  in 
infant  welfare  work  should  see  to  it  that  the  laws  provide  generous  financial 
assistance,  enough  to  amply  cover  all  the  needs  of  the  infants  and  that  the 
best  of  care  be  given  those  who  are  placed  either  in  such  institutions  as  day 
nurseries  or  infant  asyla.  Wherever  there  is  overcrowding,  babies  are 
exposed  to  the  dangers  of  respiratory  infection.  In  estimating  the  value 
of  any  of  these  modern  attempts  at  infant  welfare  work,  which  often  rep- 
resent great  pecuniary  sacrifices,  alike  on  the  part  of  the  charitable 
giver  and  the  taxpayer,  we  must  always  remember  that  their  aim  is  not 
only  to  preserve  the  lives  of  a  certain  number  of  infants,  but  also  to  guard 
the  survivors  from  serious  and  irreparable  physical  and  mental  injury.  This 
latter  is  probably  the  more  important  result  and  fraught  with  larger 
consequences  to  the  nation. 

The  care  of  children  of  the  run-about-age  has  been  provided  for  by  wel- 
fare organizations,  lay  associations  and  large  industries  by  means  of  day 
nurseries,  schools  and  the  like;  but  this  aid  is  still  inadequate  in  many 
respects.  As  we  have  already  suggested,  the  lack  of  proper  physical  care 
during  this  period  may  not  cause  any  marked  increase  of  mortality  but  it 
does  produce  a  high  morbidity.  The  after-results  of  disease  and  of  errors  in 
feeding  during  infancy  are  brought  out  with  particular  prominence  during 
this  period.  Rickets  especially  becomes  aggravated  and  results  in  more  or 
less  irremediable  deformities  of  the  extremities,  the  spine,  the  thorax,  etc. 
Perhaps  there  should  be  included  here  "bony  cavities  of  the  face " — deform- 
ities which  may  play  a  part  in  causing  chronic  nasal  infection.  It  is  at  this 
age  that  careless  training  produces  its  most  injurious  consequences,  because 
it  is  a  time  in  which  the  foundations  of  character  are  laid  and  when  the 
counter  influences  of  the  school  are  lacking. 


GENERAL  PROPHYLAXIS  AND  THERAPY      105 

Children  of  school  age  are  provided  for  in  many  ways.  In  the  building 
of  the  newer  type  of  school-houses  much  more  consideration  is  given  than 
formerly  to  air  space,  heating,  ventilation  and  lighting.  Light  should  not 
only  be  adequate  but  should  fall  over  the  child's  shoulder.  Many  new 
schools  are  indeed  models  from  a  hygienic  point  of  view.  By  providing 
abundant  daylight,  proper  fixtures  for  artificial  lighting  and  large  print  in 
school  books,  myopia,  a  school  disease,  is  measurably  avoided.  The  hygien- 
ically  correct  arrangement  of  the  desk,  with  proper  distance  between  seats, 
with  suitable  backs,  and  writing  surface  should  prevent  incorrect  postures 
from  which  scoliosis  may  arise.  It  should  be  emphasized  that  permanent 
scoliosis  is  a  definite  deformity,  generally  rickitic  in  origin,  which  may  still 
be  corrected  at  the  period  when  the  child  enters  school. 

To  safeguard  the  school  from  the  dangers  of  infection  it  is  sufficient  to 
prohibit  the  return  of  convalescents  until  the  period  of  contagion  has 
entirely  passed  and  to  exclude  early  all  children  suspected  of  communicable 
disease.  The  school  physician  should  be  the  ad  visor  of  teachers  and 
parents  upon  questions  of  hygiene.  He  should  call  their  attention  to  any 
diseases  or  abnormalities  which  he  may  discover  in  the  child.  Doubtless  by 
this  means  a  large  number  of  children  will  receive  timely  medical  attention 
which,  but  for  the  school  examination,  they  might  have  lacked.  School 
inspection  is  an  important  prophylactic  measure. 

Children  with  defects  of  the  sense  organs  and  the  seriously  crippled 
should  be  cared  for  in  special  institutions.  Subnormal  children  should 
receive  training  graduated  to  their  ability  in  separate  schools.  For  physi- 
cally weak  school  children  and  particularly  for  those  who  show  indications 
of  tuberculosis,  open-air  schools,  or  classes,  have  been  established  in  many 
communities.  Philanthropic  associations  provide  for  children  in  summer 
vacation  camps  in  the  country,  in  the  mountains  or  by  the  sea. 

An  old  question,  frequently  leading  to  heated  discussions,  based  more  on 
sentiment  than  on  actual  knowledge,  is  that  of  overwork  in  the  schools. 
It  is  not  to  be  denied  that  children  who  are  weak,  sickly  or  neuropathic  are 
easily  tired,  but  it  is  hardly  to  be  expected  that  schools  for  normal  children 
can  reduce  their  standards  or  change  their  methods  out  of  consideration  for 
a  few  abnormal  individuals.  The  selection  and  classification  of  subjects 
taught,  on  the  one  hand,  and,  on  the  other,  the  grading  of  school  children 
and  the  demonstration  of  their  degrees  of  educational  progress  are  naturally 
and  must  remain  the  problem  of  the  pedagogue  or  of  the  school  authorities. 
The  attempt  has  often  been  made  to  prove  overwork  in  the  schools  by  an 
experimental  demonstration  of  the  children's  weariness.  The  results  so 
obtained  cannot  be  accepted  without  further  corroboration.  Careful 
medical  observation,  which  alone  may  competently  decide  the  question, 
records  no  signs  of  overwork  in  the  healthy  child.  The  real  cause  of  the 
difficulty,  commonly  laid  to  the  school,  is  generally  a  matter  of  improper 
home  training.  Improper  feeding  of  the  child  may  also  be  a  not  insignif- 
icant cause  of  school  fatigue.  The  role  of  actual  underfeeding,  unbalanced 
diets,  bad  eating  habits  is  just  at  present  being  realized.  When  this  is  not 
true  and  when  the  child  cannot  keep  up  his  school  work  in  spite  of  suitable 


106  TEXT-BOOK  OF  PEDIATRICS 

home  conditions,  there  appears  no  other  alternative  but  to  give  him  more 
time  to  do  the  required  task,  or  to  put  him  in  lower  grades  where  the  work  is 
easier.  For  the  children  of  the  well-to-do,  who  for  obvious  reasons  decline 
these  alternatives,  there  are  numerous  training  institutions  or  schools  which, 
while  costly,  secure  good  educational  results  by  wise  individualization  and 
scrupulous  physical  care. 

With  legal  safeguards  against  abuse  and  industrial  exploitation  and 
with  the  work  of  humane  societies  in  caring  for  neglected  children,  the  list 
of  agencies  for  the  protection  of  the  child  is  complete.  The  delinquent  child 
is  also  coming  in  for  his  share  of  study  and  treatment. 

(6)  GENERAL  THERAPY 

If  the  well-known  axiom  of  all  therapy  that  we  must  treat  the  patient 
and  not  the  disease  is  recognized,  it  means  that  not  only  do  numerous 
variations  in  the  course  of  disease  present  indications  for  differing  thera- 
peutic measures,  but  that  over  and  above  all  other  considerations,  the 
individuality  of  the  patient  must  be  studied.  It  will  be  readily  understood 
that  the  therapy  applicable  to  childhood  and  more  particularly  to  infancy, 
presents  special  problems  incident  to  the  peculiarities  of  the  infant  organism 
and  to  the  pathology  of  childhood. 

In  the  child  certain  symptoms  or  symptom  complexes  are  characterized 
by  their  frequency  or  by  their  unusual  clinical  importance ;  and  these,  with 
the  therapeutic  methods  adapted  to  them,  will  be  discussed.  The  question 
whether  and  to  what  extent,  in  a  given  case,  a  symptom  may  be  combated 
symptomatically  must  be  left  for  inquiry  to  the  special  chapters  of  the  book. 

Fever. — If  fever  cannot  be  treated  locally,  as  by  incision  of  abscesses, 
by  paracentesis  in  purulent  otitis  media,  or  by  the  water  diet  in  alimentary 
fever,  it  may  be  treated  symptomatically  by  the  avoidance  of  food  to  pre- 
vent heat  production  or  by  the  more  commonly  practiced  attempts  to 
increase  heat  dissipation. 

The  fact  that  the  child  is  so  much  more  easily  handled  than  the  heavy 
adult  and  that  the  bath  for  the  child  is  more  simply  and  easily  prepared, 
makes  it  possible  to  use  this  cooling  agent  more  freely  than  in  later  life.  A 
bath  at  30°  C.  (86°  F.)  or  warmer,  continued  for  a  long  period,  is  more 
efficacious  than  one  in  which  the  water  is  at  20°  C.  (68°  F.),  or  colder,  which 
while  it  produces  a  rapid  cooling  of  the  surface,  yet  on  account  of  the  con- 
traction of  the  skin  capillaries  to  the  point  of  pallor,  or  even  cyanosis, 
secures  only  a  minimal  cooling  of  the  deeper  tissues.  Even  baths  at  35°  C. 
(95°  F.)  the  temperature  of  the  cleansing  bath,  without  the  addition  of 
colder  water,  will  have  a  cooling  effect,  the  difference  between  this  temper- 
ature and  that  of  the  fevered  body  of  the  child  being  great  enough  to 
produce  sufficient  reduction  of  the  body-heat  in  five  to  ten  minutes,  a 
reduction  moreover,  which  is  lasting.  Even  a  large  clinical  experience  does 
not  enable  one  to  predict  in  a  given  instance  the  amount  of  the  cooling 
effect  of  a  bath;  so  that  a  definite  time  limit  is  not  justified.  Since  the  skin 
temperature  while  in  the  bath  is  misleading,  it  may  be  well  to  interrupt 
its  application  in  order  to  take  the  actual  (rectal)  temperature  and  deter- 


107 

mine  whether  the  bath  should  be  continued.  Frequently  the  general 
condition  of  the  child,  the  clearing  of  the  sensorium,  the  improved  heart 
action,  or  on  the  other  hand,  the  appearance  of  chilliness,  will  suggest  that 
the  temperature  has  been  sufficiently  lowered. 

The  desired  effect  may  be  secured  by  moist  packs  or  may  be  attained  in 
a  simpler  manner,  which  in  many  cases  is  quite  sufficient.  With  the  moist 
pack  it  is  not  advisable  to  prescribe  the  exact  temperature  of  the  water 
because  it  is  impossible  to  control  its  changes  during  preparation.  For  an 
infant  it  suffices  to  have  the  water  at  room  temperature  or  better  still, 
somewhat  warmer.  Only  with  older  children  should  water  below  20°  C. 
(68°  F.)  be  used  and  then  only  rarely.  As  a  rule,  cooling  packs  are  applied 
only  to  the  trunk,  leaving  the  arms  free;  but,  with  high  fever,  when  a  full 
bath  is  impracticable  or  is  contraindicated,  the  extremities  may  also  be 
included  in  the  pack. 

The  sheet  intended  for  the  pack  should  be  of  six  or  eight  thicknesses  and 
should  be  wrung  dry  enough  to  prevent  dripping.  It  may  be  covered  with 
a  loosely  woven  woolen  or  knitted  blanket  so  that  evaporation  from  the 
pack  may  occur  gradually.  The  cooling  effect  depends  chiefly  upon  this 
evaporation.  So  soon  as  the  pack  becomes  dry  it  prevents  the  radiation  of 
heat  and  therefore  it  should  be  changed  at  once  or,  if  the  child  cannot  be 
moved,  it  may  be  moistened  again  by  carefully  pouring  water  over  it.  If 
the  pack  is  to  remain  in  place  for  a  long  time  it  is  well  to  protect  the  skin 
from  irritation  or  infection  by  its  inunction  with  a  bland  ointment. 

A  very  harmless,  but  less  active  form  of  cooling  is  achieved  by  the  use  of 
moist  compresses  to  the  thorax,  to  the  abdomen,  to  the  head,  or  to  the 
arms  and  legs.  Cold  sponging  of  the  skin  also  comes  under  this  head.  It  is 
especially  valuable  in  those  cases  in  which  the  child,  on  account  of  the 
nature  of  its  disease,  must  be  kept  as  quiet  as  possible.  In  the  use  of  the  ice- 
cap, which  is  best  avoided  with  infants,  care  must  be  taken  that  too  great 
cooling  does  not  take  place.  Cold  water  enemata  have  sometimes  been 
recommended  in  the  treatment  of  hyperpyrexia. 

In  comparison  with  these  hydrotherapeutic  measures,  medicinal  agents 
for  the  treatment  of  fever  in  young  children  occupy  a  less  important  place. 
Such  antipyretics  as  acetylsalicylic  acid,  antipyrin,  dimethyl-amido- 
antipyrin,  etc.,  are  of  advantage  only  when  their  use  is  dictated  by  their 
more  or  less  specific  action  in  certain  infections,  such  as  influenza,  rheuma- 
tism, some  cases  of  tonsillitis,  etc.,  or  when  they  are  simply  used  to  pro- 
voke perspiration.  Preferably  physicians  prescribe  quinine  or  one  of  its 
less  bitter  derivatives,  a  practice  justified  by  the  fact  that  quinine  not 
only  increases  heat  radiation  but  also  decreases  heat  production.  These  lat- 
ter drugs  are  little  used  in  this  country  to  control  fever. 

Antipyretics  are  more  widely  used  for  older  children,  but  even  then  only 
in  those  who  suffer  from  severe  subjective  symptoms  consequent  upon 
fever.  In  these  cases  it  is  often  possible  to  relieve  the  sleeplessness,  anorexia, 
headache,  pain  in  the  limbs,  etc.,  more  completely  and  more  easily  by  an 
antipyretic  than  by  the  use  of  baths  or  packs. 

The  use  of  alcohol,  even  though  it  has  a  cooling  effect  through  its  dila- 


108  TEXT-BOOK  OF  PEDIATRICS 

tion  of  the  peripheral  circulation,  and  although  it  produces  a  certain 
euphoria  by  its  narcotic  action,  should  be  scrupulously  avoided  in  children 
of  every  age.  It  may  be  used  as  a  stimulant  in  threatened  collapse  and  may 
be  countenanced  in  those  cases  in  which  an  increase  in  the  volume  of  the 
respiration  is  desired;  but  even  in  these  conditions,  other  remedies  may  well 
be  used.  It  is  necessary  only  to  remind  the  reader  that  besides  combating 
the  fever,  good  care  and  proper  feeding  must  be  given  due  attention. 

Most  of  the  medicinal  agents  noted,  as  well  as  the  hydrotherapeutic 
measures  employed  against  fever,  have  a  tendency  to  cause  sweating 
whenever  the  loss  of  heat  is  prevented  by  the  clothing  covering  the  patient. 
This  is  a  therapeutic  effect  often  sought  in  children,  but  with  respect  to  it, 
two  precautions  must  be  taken.  First,  it  is  not  permissible  to  give  infants 
large  quantities  of  milk  to  produce  perspiration.  Some  form  of  hot  tea, 
possibly  sweetened  with  benzosulphinidum  (saccharin)  may  be  given 
instead.  Plain  or  sweetened  water  is  the  American  equivalent  for  the 
commonly  used  tea  of  German  authors.  Second,  all  methods  of  inducing 
heat  production  or  preventing  heat  radiation  are  contraindicated  in  spas- 
mophilic  and  lymphatic  children,  since  these  measures  may  readily  cause 
hyperpyrexia  and  heart  lesions.  Pilocarpin  is  used  for  children  as  a  last 
resort  and  then  only  in  those  whose  heart  action  is  strong. 

For  combating  subnormal  temperatures,  the  same  methods  are  used  as 
are  designed  for  their  prevention,  viz.,  the  incubator,  the  warming  tub, 
hot  water  bottles,  etc.  The  use  of  the  incubator  and  of  Crede's  warming 
tub  is,  of  course,  limited  to  suitably  equipped  institutions.  In  the  home 
any  large  bottle  which  can  be  securely  corked  may  be  used.  The  attention 
of  the  mother  or  the  nurse  must  be  called  to  the  danger  of  scalding  the  infant 
from  a  leaking  bottle  or  of  burning  it  by  direct  contact  with  the  hot  bottle 
insufficiently  wrapped.  This  accident  may  also  occur  with  the  various 
forms  of  electric  heating  pads.  When  it  is  necessary  to  warm  the  child  rap- 
idly the  hot  bath  is  to  be  preferred.  Such  a  bath  may  be  begun  at  a  tem- 
perature of  35°  or  36°  C.  (95°-97°  F.)  gradually  increased  by  the  careful 
addition  of  hot  water  to  40°  C.  (104°  F.),  or  even  more.  During  this  bath 
the  child  should  be  supported  with  the  left  hand  while  it  is  rubbed  energet- 
ically with  the  right. 

Since  a  subnormal  temperature  is  usually  accompanied  by  other  mani- 
festations of  collapse,  and  particularly  by  cardiac  weakness  and  a  dimin- 
ished reaction  to  stimuli,  it  is  customary  to  counteract  the  analeptic  action 
of  the  hot  bath  by  dashing  cold  water  over  the  chest  or  back.  Slapping  the 
skin  with  a  cloth  dipped  in  cold  water  serves  the  purpose  equally  well.  These 
methods,  like  the  use  of  the  mustard  bath  or  pack,  do  not  lessen  the  bene- 
ficial effect  of  the  hot  bath,  but  on  the  contrary  they  stimulate  the  cardiac 
and  respiratory  activity.  Subnormal  temperature  frequently  indicates 
dehydration,  demineralization  or  both.  Saline  or  Ringer's  solution  by 
mouth  or  per  rectum  will  often  cause  a  return  to  normal  of  the  temperature. 

A  mustard  bath  is  prepared  by  placing  four  or  five  tablespoonfuls  of 
ground  black  mustard  in  a  muslin  sack  and  steeping  this  in  hot  water  for 
several  minutes.  By  this  means  strong  mustard  vapors  are  given  off  which 


GENERAL  PROPHYLAXIS  AND  THERAPY  109 

are  irritating  to  the  mucous  membranes  and  may  increase  an  existing 
bronchitis.  For  this  reason  the  mustard  bath  has  been  almost  entirely 
replaced  by  the  mustard  pack,  the  use  of  which  is  described  under  capillary 
bronchitis.  The  mustard  pack  cannot  be  used  with  lymphatic  children  or 
for  those  with  widespread  eczema.  In  mild  cases  or  in  emergency,  when 
neither  the  hot  bath  nor  the  mustard  pack  can  be  prepared  quickly  enough, 
the  warmth  of  the  skin  and  the  resulting  stimulation  of  the  circulation  may 
be  promoted  by  rubbing  the  body  energetically  with  the  bare  hand  or  with  a 
dry  cloth  or,  even  better,  by  rubbing  the  surface  with  spirits  of  mustard, 
camphor,  a  volatile  liniment,  or  a  mixture  of  equal  parts  of  alcohol  and  oil. 
As  internal  remedies,  alcoholic  stimulants  and  black  coffee  are  readily 
obtainable.  What  has  already  been  said  about  alcohol  applies  here  as  well. 
Its  stimulating  action  is  transitory  and  since  it  is  certainly  not  beneficial 
to  the  gastric  mucosa  it  were  better  avoided  altogether.  There  is  no  danger 
in  using  coffee,  as  hot  as  possible,  in  the  form  of  an  enema.  It  warms  the 
patient  and  at  the  same  time  has  a  stimulating  effect.  Even  when  given 
in  large  quantities,  it  is  not  followed  by  paralysis  or  by  any  other  symptoms 
of  poisoning.  Free  use  of  it,  even  in  infancy,  may  be  strongly  recommended. 
In  comparison  with  coffee,  the  stimulating  action  of  black  or  green  tea  is 
too  slight  to  justify  its  therapeutic  use. 

Medicinally  the  circulation  may  be  stimulated  most  quickly  and 
effectively  by  the  subcutaneous  injection  of  camphorated  oil.  Even  in 
infants  not  less  than  0.5  c.c.  (7  minims)  and  even  1-2  c.c.  (15-30  minims) 
may  be  used.  If  necessary,  these  doses  may  be  repeated  every  hour  for 
days  at  a  time.  Care  must  be  taken,  however,  when  so  frequent  medication 
is  employed,  that  the  injections  are  not  made  too  closely  together  lest  they 
cause  necrosis  and,  in  cases  of  existing  bacteriemia,  abscesses. 

Caffein,  with  sodium  benzoate,  may  be  given  to  infants  of  six  months, 
or  over,  in  doses  of  0.03  gm.  (^  gr.);  in  doses  of  0.06  gm.  (1  gr.),  during 
the  second  and  third  years;  or  0.1  gm.  (2  grs.),  during  the  fourth  to  the 
sixth  year;  and  in  children  of  school  age,  0.15-0.20  gm.  (2-3  grs.),  three  to 
four  tunes  a  day.  Such  doses  may  be  prescribed  in  a  ten  to  twenty  per  cent, 
solution  in  sterile  water.  Its  action  is  quick  but  not  lasting. 

For  very  rapid  results,  epinephrin,  is  very  useful.  From  0.2-0.3  c.c. 
(3-5  minims)  of  a  1 : 1000  solution  may  be  used  for  one  intramuscular  injec- 
tion in  infants.  Still  larger  doses  may  be  given  older  children.  As  an 
adjuvant  to  the  intravenous  transfusion  of  saline  solution  it  meets  with 
insuperable  technical  difficulties  in  young  children,  but  Pospischill  has 
succeeded  in  the  subcutaneous  injection  of  as  much  as  60  drops,  in  150  c.c. 
of  physiologic  salt  solution,  as  often  as  two  to  four  times  a  day,  in 
older  children. 

Digitalis  acts  more  slowly  and,  therefore,  for  a  longer  time.  An  infusion 
of  digitalis 0.3-0.5  gm.  (5  to  8  grs.)  in  100  c.c.  (3  ounces),  for  infants  and  even 
more  for  older  children  may  be  used  within  a  period  of  three  days.  On  ac- 
count of  the  cumulative  action  of  digitalis  it  is  necessary,  if  the  drug  is  used 
for  a  long  period,  to  alternate  its  exhibition  with  intervals  of  withdrawal. 
During  these  intervals  the  tincture  of  strophanthus  (1-5  drops,  every  three 


110  TEXT-BOOK  OF  PEDIATRICS 

hours),  or  caffein  may  be  given.  Instead  of  the  infusion  of  digitalis,  digalen, 
digitoxine  soluble  or  a  solution  of  digipuratum  may  be  used  with  good 
results.  Of  either  of  these  preparations  two  or  three  drops  may  be  given 
to  infants,  and  ten  or  twelve  to  older  children,  three  times  daily.  Sterile 
digalen  and  digipuratum,  or  similar  preparations,  are  obtainable  in  ampules 
and  may  be  injected  intravenously  or  intramuscularly  if  more  rapid 
absorption  is  desired.  Their  influence  upon  the  circulation  is  decidedly 
less  marked  than  that  of  the  infusion  but  it  is  equaHy  necessary  to  watch  for 
its  appearance  and  especially  for  the  possible  retardation  of  the  pulse.  The 
effect  of  drugs  of  the  digitalis  group  is  often  difficult  to  estimate,  especially 
in  young  children  and  the  dosage  therefore  will  depend  on  conditions.  The 
quantities  given  above  are  to  be  regarded  as  average  doses  and  more  may  be 
freely  given — usually  in  vain — where  severe  cardiac  collapse  is  apparent. 

All  of  the  so-called  heart  stimulants  act,  also,  as  stimulants  of  respir- 
ation, but  they  fail  in  cases  in  which  paralysis  of  respiration  is  the  most 
prominent  symptom,  as  indicated  by  the  alternation  of  respiratory  pauses 
and  periodic  breathing  while  the  heart  action  remains  actually  or  relatively 
strong.  In  such  cases  the  inhalation  of  three  litres  of  oxygen  a  minute,  for 
five  or  ten  minutes,  repeated  two  or  three  times  in  an  hour,  may  relieve 
the  exhausted  expiratory  centre  and  by  relieving  it  and  thus  increasing 
the  oxygenation  of  the  blood  may  interrupt  a  dangerous  vicious  cycle. 
With  the  exception  of  laryngeal  stenosis,  I  have,  however,  scarcely  ever 
observed  a  permanent  result  even  if  oxygen  is  given  in  large  quantities  al- 
though temporary  benefit  was  achieved. 

If  the  disturbance  of  respiration  is  due  to  obstruction  of  the  nasal 
breathing,  often  occurring  in  young  children  who  experience  some  dif- 
ficulty in  learning  to  breath  through  the  mouth,  relief  may  be  obtained 
by  the  mechanical  cleansing  of  the  nose  with  a  dry  cotton  applicator,  or 
with  cotton  saturated  with  glycerin,  or,  if  there  is  much  swelling,  with 
epinephrin.  Cotton  tampons,  moistened  with  a  fresh  solution  of  epineph- 
rin  1 : 3,000  may  be  placed  in  the  nostril  after  it  has  been  cleaned.  Seri- 
ous obstruction  of  respiration  in  the  larynx  may  necessitate  intubation 
or  tracheotomy. 

In  infancy  the  problem  of  preventing  a  dangerous  loss  of  water  from  the 
body  or  of  stopping  such  loss  as  quickly  as  possible  often  presents  itself. 
The  most  simple  method,  that  of  permitting  the  child  to  drink  large  quan- 
tities of  physiologic  salt  solution,2  or  of  slightly  alkaline  mineral  water,  or  of 
weak  tea  containing  salt,  is  often  thwarted  because  the  seriously  sick  child 
refuses  fluids  or  because  of  persistent  vomiting.  In  these  cases,  it  is  often 
possible  to  obtain  the  same  results  by  repeated  rectal  injections  of  these 
solutions,  in  quantities  of  50-100  c.c.  (13^-3  ounces)  at  body  temperature, 
by  means- of  a  Nelaton  catheter  introduced  as  far  as  possible.  To  prevent 
the  immediate  expulsion  of  the  fluid,  the  nates  should  be  gently  pressed 
together  for  several  minutes.  If  it  proves  impossible  to  secure  the  absorp- 
tion of  sufficient  fluid  from  the  bowel  by  this  method,  enteroclysis,  a  more 
elegant  method  of  administration,  may  often  be  employed  successfully. 

2  For  the  explanation  of  the  reason  for  the  addition  of  salt,  see  Chapter  I,  page  18. 


GENERAL  PROPHYLAXIS  AND  THERAPY  111 

The  apparatus  for  enteroclysis  consists  of  an  irrigator  with  a  long  rubber 
tube,  controlled  by  a  glass  stop-cock  with  a  catheter  attached  to  it.  The 
catheter  is  passed  as  high  as  possible  into  the  rectum  and  held  in  place  by 
adhesive  straps.  The  flow  is  regulated  by  means  of  the  stop-cock,  so  that 
30-40  drops  a  minute,  or  90-120  c.c.  (3-4  ounces)  an  hour  are  instilled.  By 
this  method  it  is  possible,  without  causing  distension,  to  give  200  c.c.  (6 
ounces)  several  times  a  day.  Any  of  the  solutions  mentioned  above  may  be 
used  or,  to  avoid  the  pyrogenetic  action  of  the  sodium  chloride,  Ringer 's  so- 
lution (sodium  chloride  7.5  g. ;  potassium  chloride  0.42  g. ;  calcium  chlo- 
ride 0.24  g.  per  litre)  may  be  instituted.  The  rectal  application  of  many 
other  drugs  may  be  practiced  to  the  advantage  of  the  patient.  Sodium 
bicarbonate  in  2-5  per  cent,  solution  and  glucose  are  frequently  used.  The 
latter  substance  is  tolerated  even  by  the  infant  in  surprisingly  high  con- 
centrations. I  have  given  up  to  25  per  cent,  glucose  solutions  to  infants 
without  the  least  sign  of  irritation. 

The  most  rapid  and  certain  method  of  increasing  the  fluids  of  the  body 
is  by  hypodermoclysis,  in  which  either  sterile  physiologic  salt  solution 
(0.7  per  cent.  )  or,  preferably,  Ringer's  solution  may  be  used. 

A  large  serum  syringe  or  a  canula,  attached  to  a  funnel  by  means  of 
rubber  tubing  may  be  employed  for  the  purpose.  In  infants  who  have 
lost  much  water,  from  50  c.c.  to  100  c.c.  (lj^-3  ounces)  may  be  introduced. 
This  quantity  may  be  injected  gradually  through  a  single  puncture  of  the 
skin  over  the  chest,  abdomen  or  back  by  occasionally  moving  the  needle. 
Its  painfulness  has  reserved  this  method  for  extreme  cases  in  which,  how- 
ever, it  is  often  the  only  means  of  saving  the  patient,  when  it  may  be  re- 
peated as  often  as  four  times  a  day.  The  intraperitoneal  injection  of  salt 
solutions  is  also  now  being  practiced  more  than  in  the  past. 

Frequently  and  under  varying  circumstances,  it  is  found  necessary  to 
induce  rapid  and  complete  emptying  of  the  intestinal  tract.  Enemata  or 
colonic  flushings  empty  the  large  intestines  only  and  are  especially  efficient 
when  it  is  necessary  to  remove  hardened  fecal  masses  from  the  lower  bowel. 

In  using  the  small  rectal  syringe,  which  carries  30-50  c.c.  (1-1/4  ounces), 
the  hard  rubber  tip  should  not  be  directly  introduced  into  the  bowel, 
because  by  any  unexpected  movement  of  the  child  serious  injury  may  be 
produced.  The  tip  should  be  armed  with  a  Nelaton  catheter  or  a  rectal 
tube.  This  is  also  true  of  the  hard  rubber  irrigator  tip..  A  rectal  tube, 
which,  even  for  the  infant  may  have  the  circumference  of  the  little  finger, 
should  be  inserted  as  far  as  possible,  the  pelvis  being  propped  upon  a  pillow 
with  the  child  lying  on  its  back  or  side.  The  nates  should  be  pressed  gently 
together  after  the  injection,  in  order  to  hold  the  enema  in  the  bowel  for  a 
little  while  to  permit  it  to  dissolve  the  scybala. 

The  enema  may  also  serve  the  purposes  of  a  flushing.  For  this  purpose 
it  is  better  to  use  a  funnel  attached  to  the  tube  rather  than  the  irrigator. 
The  tube  should  be  somewhat  larger  than  that  used  in  gastric  lavage 
(q.  v.}.  A  tepid  physiologic  salt  solution,  or  astringent,  laxative,  anti- 
parasitic  antiseptic  solutions,  etc.,  may  be  used  according  to  the  desired 
effect.  Enemata  of  30-100  c.c.  (1-3  ounces)  of  oil  will  serve  to  soften  scybala. 


112  TEXT-BOOK  OF  PEDIATRICS 

Glycerin,  one  or  two  teaspoon! uls  with  an  equal  quantity  of  water,  is  said  to 
act  as  a  stimulus  to  the  peristalsis  of  the  lower  bowel.  An  identical  result 
may  be  had  by  the  insertion  in  the  rectum  of  the  well-known  glycerin 
suppository,  small  forms  of  which,  suitable  for  children,  are  obtainable ;  or 
by  the  similar  use  of  the  soap  stick,  a  common  domestic  device,  of  about  the 
thickness  of  the  little  finger  and  from  3-5  cm.,  (1-2  inches)  long,  prepared 
from  any  ordinary  laundry  soap. 

The  medicinal  cathartics  are  much  more  satisfactory  for  the  complete 
evacuation  of  the  whole  intestinal  tract.  For  decades,  calomel  has  unde- 
servedly ranked  as  the  most  popular  cathartic.  A  dose  of  0.01-0.05  gm. 
(3^5-1  gr.)  may  be  given  to  the  infant,  and  from  0.05-0.1  gm.  (1-2  grs.)  to  the 
child  of  three  years,  or  more  may  be  given  every  two  hours  until  results  are 
obtained.  That  calomel  has  the  obstipating  effect  ascribed  to  it  when  it  is 
given  in  small  and  infrequent  doses  is  a  very  questionable  matter,  since  it  is 
not  an  intestinal  antiseptic.  There  is,  however,  no  doubt  that  it  frequently 
produces  an  intestinal  irritation  far  in  excess  of  its  desired  result  and  that  it 
is  injurious  at  least  in  so  far  as  it  increases  the  intestinal  secretion  which  is 
very  prone  to  decomposition  and  putrefaction.  For  this  reason,  it  is 
hardly  ever  given  to  infants  by  the  modern  podiatrist.  Its  place  has  been 
taken  by  castor  oil,  a  much  less  harmful  remedy  which  young  children  take 
readily,  especially  if  it  has  been  thinned  by  warming  it  in  the  spoon.  It 
should  be  given  in  sufficiently  large  doses  of  one  or  two  teaspoonfuls  at  a 
time.  Older  children  will  take  it  without  objection  if  the  tongue  is  first 
covered  with  sweet  chocolate  or  if  the  oil  is  given  in  the  form  of  an  emulsion 
with  equal  parts  of  the  aromatic  syrup  of  rhubarb  as  recommended  by 
Henoch.  Milk  of  magnesia  can  be  used  for  those  infants  and  children  in 
whom  the  mildest  laxative  action  is  desired. 

Phenolphthalein,  in  tablet  or  candy  form,  is  very  efficacious  in  children 
of  three  years  or  more.  It  produces  one  complete  evacuation  of  the  bowels 
and  is  entirely  painless  in  action.  In  younger  children  castor  oil  or,  if 
necessary,  the  compound  rhubarb  powder  will  usually  be  found  adequate. 

In  older  children,  the  saline  laxatives  may  be  considered,  particularly 
in  that  degree  of  habitual  obstipation  which  demands  medicinal  treatment. 
It  is  best  to  begin  with  one  teaspoonful  of  artificial  Carlsbad  salts  in  a 
wineglassful  of  warm  water,  increasing  or  diminishing  the  dose  as  required. 
Syrup  of  senna  may  be  used,  but  it  is  somewhat  objectionable  on  account  of 
the  colic  which  it  is  apt  to  cause. 

For  the  forced  emptying  of  the  stomach  emetics  are  seldom  used  now- 
a-days;  since  the  result  may  be  attained  with  less  injury  and  more  com- 
pletely by  gastric  lavage,  which  is  technically  simple  in  young  children.  The 
child  is  laid  upon  its  side,  with  its  face  slightly  downward,  as  shown  in 
Figure  22,  so  that  any  vomited  matter  passing  along  the  side  of  the  tube  may 
run  off  and  escape  aspiration — the  only  caution  that  needs  to  be  observed. 
The  apparatus  employed  consists  of  a  funnel  of  150-200  c.c.  (5-8  ounces) 
capacity,  to  which  a  catheter  of  about  the  diameter  of  a  lead  pencil  is 
attached  by  means  of  a  piece  of  tubing  about  a  yard  long.  This  should  have 
glass  connections  but  no  stop-cock.  In  the  infant,  the  catheter  serves  well 


GENERAL  PROPHYLAXIS  AND  THERAPY  113 

as  a  stomach  tube.  Being  passed  directly  to  the  posterior  pharyngeal  wall 
it  causes  slight  gagging  and  then  swallowing  movements.  The  catheter  is 
passed  very  readily.  There  is  no  danger  of  forcing  the  tube  into  the  larynx 
and  the  first  slight  gagging  soon  stops  if  the  tube  is  quietly  held  in  place  for 
a  moment.  The  rest  of  the  maneuver,  the  extraction  of  the  stomach  con- 
tents, and  the  washing  with  water  or  with  physiologic  salt  solution  at  body 
temperature  is  carried  out  as  it  is  in  the  adult.  The  tube  must  be  moved  up 
or  down  a  few  centimeters  so  that  its  eye  dips  into  the  fluid,  instead  of  lying 


Fio.  22. — Gastric  lavage. 

in  the  air  space  above,  the  so-called  "gastric  bubble,"  in  order  to  remove  the 
last  remnant  of  fluid  used.  A  few  large  curds,  which  occasionally  form  in  the 
atonic  stomach,  may  escape  the  lavage,  but  for  its  therapeutic  purposes 
this  is  of  no  great  importance.  The  addition  of  various  medicinal  agents  in 
lavage  has  not  been  found  practical.  The  use  of  the  stomach  tube  for  pur- 
pose of  feeding,  where  food  cannot  be  taken  or  where  it  is  refused,  deserves 
especial  emphasis. 

Of  the  various  astringents  employed  in  the  treatment4  of  the  diseased 
intestine,  tannin  is  still  in  most  common  use.    In  irrigation  of  the  bowels  a 
.25  per  cent,  or  .33  per  cent,  solution  is  preferred,  but  it  reaches  only  the 
8 


114  TEXT-BOOK  OF  PEDIATRICS 

lower  portion  of  the  large  intestine.  To  affect  the  entire  tract,  tannin  must 
be  given  by  mouth.  Many  modern  preparations  which  pass  the  stomach 
more  or  less  unchanged  and  which  gradually  liberate  tannic  acid  in  the 
intestine,  such  as  diacetylic  tannic  acid,  tannigen,  tannalbin,  tannoform, 
tannismut  and  others  are  available.  Since  any  excess  passes  through  un- 
changed it  is  not  necessary  to  gauge  the  prescribed  amount  carefully.  Bulk 
powder  is  usually  ordered  with  directions  to  give  a  small  quantity  several 
times  a  day.  As  the  powder  is  insoluble  and  rather  bulky  it  is  best  given 
stirred  into  a  thick  gruel. 

A  two  per  cent,  of  aluminum  acetate  maybe  used  for  irrigation  instead  of 
the  tannic  acid  solution.  Starch  enemata  (1  teaspoonful  of  starch,  in  150- 
200  c.c.  (5-7  ounces  water),  water  heated  to  form  a  paste.  Of  this  solution 
30-50  c.c.  (1-2  ounces)  may  be  injected  at  body  temperature.  Although  fre- 
quently recommended,  it  has  no  astringent  action  but  may  be  used  as  a 
vehicle.  The  starch  is  supposed  to  act  as  a  protection  to  the  mucous 
membrane  but  this  effect  seems  to  be  rather  doubtful. 

Beside  the  tannin  preparations,  bismuth  is  often  prescribed  as  a  medi- 
cinal astringent.  Bismuth  subnitrate  or  subsalicylate  suspended  in  muci- 
lage of  acacia  (20  gms.  to  100  c.c.)  may  be  given  to  infants  in  doses  of 
0.2-0.3  gm.  (3-5  grs.)  every  three  hours.  The  stools  become  grayish-black 
from  the  bismuth  and  sulphur  compound  which  is  formed  in  the  intestine. 
Tannismuth,  colloidal  bismuth  oxide  (Birmon),  etc.,  are  new  preparations 
of  bismuth  which  may  be  used. 

The  anti-diarrhoeic  action  of  these  preparations  depends  upon  their 
astringent  action  and  their  diminution  of  the  secretions.  Kaolin  (bolus 
alba)  and  animal  charcoal  (carbo  animalis)  given  in  large  doses  [5-10  gms. 
(45  grs. — 1  dram)  in  100-150  cc.  (3-5  ounces)  of  boiled  water]  three  times 
daily  has  a  different  effect.  It  is  of  purely  mechanical  influence,  due  to  the 
fact  that  the  fine  grains  of  the  powder,  thoroughly  mixed  with  the  intestinal 
content,  prevent  the  access  of  the  intestinal  bacteria  to  their  nutritive 
media  and  thus  limit  their  fermentative  action.  Unless  the  intestinal  canal 
is  at  least  in  part  cleaned  of  its  contents  or  unless  no  food  is  being  given, 
little  is  to  be  expected  of  the  bolus  or  charcoal  therapy. 

Opium  as  an  anti-diarrhoeic  measure  in  children  demands  special  dis- 
cussion. Its  danger  to  the  infant  organism  has  been  generally  over-esti- 
mated and  evidences  of  disorder  which  really  belong  to  the  picture  of 
certain  severe  alimentary  disturbances  have  been  erroneously  regarded  as 
the  result  of  small  doses  of  opium.  For  this  reason  the  use  of  opium  has 
been  generally  condemned  in  young  children.  It  is  true  that  opium  is  not 
often  indicated  for  its  anti-peristaltic  effect,  but  while  it  diminishes  peri- 
stalsis and  to  a  certain  extent  absorption,  it  does  not  in  any  way  diminish 
the  decomposition  going  on  in  the  intestinal  contents.  Just  as  its  use  is 
justified  for  the  control  of  a  spasmodic  cough,  so  its  symptomatic  employ- 
ment is  permissible  to  arrest  too  frequent  evacuations,  excessive  loss  of 
water,  severe  colic  or  repeated  rectal  prolapse.  It  is  clear,  however,  that 
this  symptomatic  treatment  may  mask  a  serious  basic  disease,  which  in 
young  infants  clinical  experience  teaches  is  often  a  very  dangerous  thing. 


GENERAL  PROPHYLAXIS  AND  THERAPY      115 

As  to  the  dosage  of  opium,  H.  Neumann  advises,  perhaps  quite  too 
conservatively,  the  addition  of  one  drop  of  the  tincture  or  wine  of  opium  to 
50  c.c.  (1%  ounces)  of  water  of  which  solution  infants  under  six  months  of 
age  receive  one  teaspoonful  and  in  the  second  half-year  a  dessertspoonful, 
(1^/2  drams),  every  hour,  until  the  bowel  movements  have  been  stopped  for 
three  hours.  With  increasing  age  the  dosage  is  advanced,  until  children  of 
three  to  six  or  eight  years  receive  three  to  six  drops  not  oftener  than  every 
three  hours.  These  doses  are  exceeded  only  in  exceptional  cases,  as  for 
example,  in  appendicitis  or  peritonitis.  In  such  cases  it  is  better  to  use  the 
drug  in  the  form  of  extract  of  opium  given  in  suppositories.  So  prescribed, 
0.01-0.02  gm.  (M-H  gr-)  may  be  used  for  children  from  three  to  six  years 
old;  and  0.02-0.03  gm.  (H-^4  gr-)  f°r  older  children  according  to  necessity, 
three  or  four  times  a  day. 

Hot  compresses,  very  hot  dry  packs,  or  poultices  applied  to  the  abdo- 
men to  relieve  severe  abdominal  pains,  may  be  used  instead  of  opium. 
While  their  action  is  less  certain  they  are  entirely  harmless.  Dry  appli- 
cations must  be  changed  frequently  and  at  least  every  half  or  three-quarters 
of  an  hour;  they  should  be  very  hot  and  covered  with  dry  cloths.  The 
favorable  influence  ascribed  by  mothers  and  practical  nurses  to  the  various 
kinds  of  herb-tea  in  the  relief  of  colic  is  probably  not  specific.  They  are 
permissible,  since  when  they  are  being  given  the  child  usually  receives  no 
other  food — a  most  important  indication  in  such  cases. 

Aside  from  the  drugs  noted,  the  use  of  narcotics  in  children  should  be 
confined  to  the  relief  of  troublesome  cough  and  the  induction  of  sleep. 
The  first  of  these  objects,  the  more  complete  discussion  of  which  is  left  to 
special  chapters,  we  will  treat  but  briefly  here.  The  most  useful  narcotic  is 
codein  sulphate,  dissolved  in  sweetened  water.  It  may  be  given  to 
infants  in  initial  doses  of  0.002  gm.  (Mo  gr.)  three  or  four  times  a  day. 
In  some  cases  it  may  be  necessary  to  increase  the  dose  materially,  0.003- 
0.005  gm.  (/^O'Ma  Sr-)  in  order  to  obtain  results.  In  children  of  the 
run-about-age,  a  further  increase  to  0.01-0.015  gm.  (K~M  gr.)  may  be 
required.  If  codein  in  these  doses  does  not  produce  the  desired  effect,  the 
use  of  morphin  sulphate,  which  in  children  is  fully  as  objectionable  as 
opium,  is  permissible,  but  requires  careful  observation.  The  doses  should 
be  about  one-third  as  large  as  those  of  codein. 

The  soporifics  require  more  detailed  consideration.  Habitual  insomnia, 
either  a  difficulty  in  falling  asleep,  which  may  continue  for  a  period  of  hours 
or  an  abnormally  light  sleep  is  not  at  all  uncommon  during  childhood. 
Since  in  insomnia  we  have,  to  deal  with  a  general  neuropathic  symptom, 
therapeutic  measures  must  be  aimed  at  the  basic  disorder,  or  rather,  in  a 
given  case,  must  be  directed  to  the  training  and  environment  which  have 
led  to  the  disturbance  of  sleep.  It  is  better  to  treat  the  case  with  tepid 
packs  or  long  continued  hot  baths,  etc.,  than  to  employ  sleep-producing 
drugs,  which  should  be  reserved  for  exceptional  cases.  This,  is  not  true, 
however,  of  a  temporary  sleeplessness,  caused  by  severe  acute  disease, 
which  in  itself  weakens  the  patient.  The  uncontrollable  restlessness  of 
certain  infants  suffering  with  disturbances  of  nutrition  or  the  sleeplessness 


116  TEXT-BOOK  OF  PEDIATRICS 

which  occurs  with  older  children  in  the  course  of  septic  fevers,  typhoid, 
miliary  tuberculosis,  etc.,  is  of  this  order.  Under  such  circumstances,  the 
indications  for  procuring  sound  sleep  are  no  doubt  pressing.  In  infants  the 
most  common  remedy  employed  for  this  purpose  is  chloral  hydrate.  Since 
this  drug  acts  rapidly,  it  is  well  to  give  one  teaspoonful  of  a  one  to  two  per 
cent,  solution,  every  fifteen  minutes  or  half  an  hour  until  sleep  is  produced. 
By  this  method  of  administration  no  injury  is  ever  done  and  even 
though  the  patient  be  especially  resistant  to  the  drug  we  are  usually  quite 
certain  to  obtain  the  desired  effect.  Of  course  the  doses  required  will  vary- 
greatly,  several  decigrams  being  necessary  in  some  cases.  Even  a  single 
dose  of  0.5-1.0  gm.  (7^-15  grs.)  given  in  a  two  per  cent,  solution  per  rec- 
tum in  a  case  of  frequent  eclamptic  convulsions  in  infancy,  is  wholly  with- 
out injurious  effect  upon  the  heart  or  the  blood-pressure  and  will  stop  the 
attacks  within  ten  or  fifteen  minutes  and  produce  several  hours  of  sleep. 

Chloral  hydrate  is  a  very  good  soporific  fer  older  children,  but  is  often 
refused  because  of  its  acrid  taste.  As  a  substitute  diethyl-barbituric-acid 
[veronal  0.1-0.3  gms.  (2-5  grs.),  for  children  from  three  to  twelve  years  old] 
or  sodium  diethyl-barbiturate  (sodium-veronal)  which  is  more  soluble  and 
therefore  acts  more  rapidly,  is  excellent. 

Since  soporifics  are  only  required  temporarily,  and  often  for  a  single 
dose,  there  is  no  necessity  for  change;  these  remedies,  therefore  will  be 
found  sufficient. 

The  discussion  of  the  expectorants,  indicated  in  congestion  of  the  smaller 
air  passages,  due  either  to  the  absence  of  the  cough  stimulus  or  to  the 
viscosity  of  the  secretion;  of  the  narcotics,  as  employed  for  the  relief  of 
cough;  of  the  diuretics,  hemostatics,  anthelmintics,  and  of  the  entire 
armamentarium  of  serum  therapy  may  be  referred  to  special  chapters  of 
this  work. 

The  group  of  tonics,  however,  requires  general  discussion,  since 
children  who  are  subject  to  such  treatment  are  very  common  in  every 
physicians '  practice.  A  child  is  often  brought  to  the  pediatrist  with  a  lay 
diagnosis,  sanctioned  actively  or  passively  by  the  physician  of  "watery 
blood"  or  anemia,  based  upon  the  patient's  faulty  nutrition,  pallor  and  ap- 
parent weariness,  or  upon  a  series  of  such  functional  disturbances  as  head- 
ache, anorexia,  etc.  The  pediatrist  is  then  expected  to  relieve  the  condition 
by  means  of  tonic  remedies. 

The  number  of  preparations  offered  for  this  purpose  is  so  great  that 
no  physician  need  hesitate  for  a  choice  if  he  is  willing  to  prescribe  untried 
remedies  without  reference  to  their  effect  in  any  particular  case.  A  large 
field  is  open  to  him  who  wishes  to  make  more  or  less  aimless  trial  of  these 
innumerable  combinations  of  nutrients  and  alterants,  into  which  iron, 
arsenic,  iodine,  quinine  and  phosphorus  enter  in  indiscriminate  variation. 
It  goes  without  saying  that  such  methods  are  unworthy  of  the  thinking 
physician  and  are  not  to  be  excused  by  the  ignorance  of  anxious  parents. 
Even  if  the  physician  wishes  to  employ  a  medicinal  agent  for  its  purely 
suggestive  influence,  he  must  nevertheless  determine,  through  physicial 
examination  and  careful  inquiry  into  the  manner  of  life  and  the  training 


GENERAL  PROPHYLAXIS  AND  THERAPY  117 

of  the  child,  the  basic  cause  of  the  given  disease  and  must  attempt,  as  a 
physician  and  an  educator,  the  removal  of  such  cause.  A  large  share  of  the 
disturbances,  which  lead  to  a  demand  for  this  sort  of  therapy,  are  of  func- 
tionally nervous  origin  in  children,  as  they  are  in  adults.  In  early  child- 
hood, suggestive  therapeutics  of  a  medicinal  character  have  not  the  same 
justification  as  they  bear  when  they  are  addressed  to  the  adult',  because 
young  persons  are  not  responsive  to  such  measures.  The  empiric  use  of 
the  so-called  alterants  is  the  more  narrowly  restricted  on  this  account. 

Information  concerning  blood-forming  remedies,  with  reference  to 
their  usefulness  in  hemic  disease,  may  be  found  in  the  chapter  on  Anemia. 

The  artificial  food  preparations  of  which,  also,  an  extremely  large  num- 
ber are  on  the  market,  are  used  very  extensively  for  children  who  are  either 
well  or  ill.  While  extended  study  of  the  pathology  of  infancy  has  taught 
the  podiatrist  definite  indications  for  the  increase  or  decrease  of  the  several 
elements  of  the  selected  dietary,  older  children  are  carelessly  given  these 
manufactured  preparations  upon  the  strength  of  preformed  conclusions 
of  merit  or  of  accidental  successful  experience  of  their  use. 

The  feeding  of  artificial  protein  preparations  is  not  justified  for  the 
purpose  of  increasing  the  deposit  of  fat  in  a  lean  child.  Only  when  an 
exhausting  disease  has  reduced  the  protein  content  of  the  organism  and  it  is 
desired  to  increase  the  nitrogen  retention,  by  an  increase  of  the  nitrogen 
intake,  is  such  a  procedure  indicated.  Under  any  other  circumstances  high 
intake  results  in  an  increased  nitrogenous  output  which  cannot  be  con- 
sidered desirable.  Of  food  preparations  consisting  largely  of  fats  or  carbo- 
hydrates, the  former,  if  they  are  well  borne,  must  be  given  the  preference. 
A  justly  high  value  has  been  placed  upon  cod-liver  oil  and  its  emulsions; 
but  this  cannot  be  extended  to  the  substitutes  for  cod-liver  oil,  since  these 
are  of  entirely  different  chemical  composition.  Among  the  carbohydrate 
preparations  the  numerous  malt  extracts,  often  combined  with  iron,  io- 
dine, etc.,  enjoy  some  popularity.  Several  of  these  have  a  mildly  laxative 
action,  which  dry  maltose  and  dextrin  preparations  do  not  possess.  A  favor- 
ite food  of  high  carbohydrate  content  and  always  in  favor  with  children  is 
cocoa  or  chocolate. 

Even  physicians  who  permit  the  temporary  use  of  alcoholics  or  con- 
sider them  necessary  in  cases  of  acute  weakness,  unamimously  condemn  the 
daily  use  of  alcoholic  tonics  or  of  wine,  heavy  beer,  etc.  Alcohol  should 
be  used  only  as  a  vehicle  for  other  drugs  and  especially  for  the  stomachics, 
as  in  the  wine  of  pepsin  or  the  aromatic  tinctures  (compound  tincture  of 
cinchona,  etc.),  which  are  given  by  the  teaspoonful  or  by  drops.  The  action 
of  agents  which  stimulate  the  appetite  chiefly  by  their  taste  is  naturally 
very  slight  in  young  children;  but  in  older  ones  is  more  definite.  Pepsin 
and  dilute  hydrochloric  acid,  in  teaspoonful  doses,  immediately  before  or 
after  feeding,  are  occasionally  useful;  but  it  should  be  remembered  that  a 
temporary  loss  of  appetite  may  dictate  a  wise  refusal  of  food  which  may  not 
be  combated  without  harm. 

In  the  habitual  anoiexia  of  children  of  the  run-about  or  school  age,  such 
remedies  as  ichthyol  albuminate  and  the  like,  give  much  less  satisfactory 


118  TEXT-BOOK  OF  PEDIATRICS 

results  than  does  a  careful  regulation  of  the  diet.  Feeding  should  never  be 
urged.  It  is  especially  necessary  to  treat  the  frequently  coexisting  habit  of 
obstipation.  These  and  other  influences,  not  infrequently  chronic  infection 
of  the  nose  and  throat,  affecting  the  psychic  well-being  of  the  small  patient 
should  be  removed.  The  child  is  often  of  a  nervous  temperament  and  sur- 
rounded by  neurotic  adults  and  it  is  sometimes  necessary  to  place  it  in 
entirely  new  and  more  favorable  surroundings.  The  surprisingly  good 
results  often  attaching  to  its  removal  to  a  children 's  home  in  the  mountains 
or  by  the  seaside  are  largely  due  to  a  change  of  environment. 

While  the  psychologic,  factors  of  treatment  are  particularly  empha- 
sized, it  is  not  to  be  denied  that  such  hygienic  influences  as  light,  air, exercise, 
bathing,  etc.,  are  largely  involved  in  bringing  about  a  good  result.  Never- 
theless, it  remains  true  that  the  reputed  benefits  of  a  change  of  air  are 
achieved  less  by  climatic  than  by  psychic  agencies.  Especial  weight  is  to  be 
given  to  intensive  exercise  in  the  open,  which,  with  its  variable  qualities, 
does  not  become  tedious  and  does  much  to  alleviate  the  illness  of  the  child. 
The  action  of  light  is  only  second  in  value,  while  bathing  is  a  less  important 
matter.  This  conclusion  seems  justified  by  the  fact  that  sea-baths  given  at 
home,  in  the  patient's  habitual  surroundings,  have  little  or  no  effect. 
Furthermore,  the  strong  stimulation  of  the  skin  and  the  nervous  system 
induced  by  cold  sea-bathing,  by-the-sea,  must  be  more  carefully  watched 
and  adapted  to  the  conditions  of  the  child  than  is  necessary  in  the  enjoy- 
ment of  the  less  active  influences  of  light,  air  and  pleasurable  exercise.  In 
every  case  the  attendant  should  see  to  it  that  cold  sea-baths  are  of  very 
short  duration,  not  exceeding  one  or  two  minutes,  that  the  child  moves 
about  actively  in  the  water  and  is  warmed  up  as  rapidly  as  possible  after 
the  bath. 

When  a  number  of  children  are  bathing  together  it  is  usually  possible 
to  make  the  timid  among  them  go  into  the  water  without  persuasive  force. 
If  this  is  not  possible,  and  skilful  and  repeated  attempts  at  persuasion  fail, 
the  repetition  of  force  in  giving  the  child  the  cold  bath  only  increases  fear 
and  becomes  an  injury  to  the  nervous  system. 

Sea-salt  and  sun-baths  have  become  widely  popular  in  the  effort  to 
build  up  feeble  and  particularly  scrofulous  children.  Experience  cor- 
roborates the  conclusion  already  reached  that  at  best  they  are  but  ad- 
juvants of  treatment  and,  as  given  in  the  home,  are  inefficient,  whereas, 
when  combined  with  other  therapeutic  measures  at  the  sea-side,  they  seem 
more  effective. 

In  the  matter  of  technique,  the  following  may  be  noted:  Enough  salt, 
(table  salt,  sea-salt)  is  used  in  the  bath  to  make  a  1.5-2  per  cent,  solution, 
using  30-40  litres,  or  7-8  gallons,  of  water  for  infants  and  100-200  litres,  or 
25-50  gallons,  for  older  children.  If  there  is  much  insoluble  sediment,  the 
salt  may  be  first  dissolved  in  boiling  water  and  then  strained  into  the  bath. 
The  bath  temperature  should  be  32-33°  C.  (88°-90°  F.)  for  the  babe,  and 
about  30°  C.  (86°  F.)  for  the  older  child,  a  little  less  than  that  of  the  ordinary 
bath.  It  should  be  given  for  ten  or  fifteen  minutes.  Frequently  the  bath  is 
followed  by  a  cool  rub  down  in  the  sun,  to  increase  the  reaction  of  the  skin. 


GENERAL  PROPHYLAXIS  AND  THERAPY      119 

It  is  well  to  begin  with  two  baths  a  week  and  to  increase  the  number  only  if 
the  patient  reacts  well. 

Convenient  as  it  would  be  for  the  physician,  it  is  impossible  to  give  any 
definite  directions  for  the  dosage  of  various  drugs  in  childhood.  A  very 
indefinite  approximation  may  be  made  by  giving  that  fraction  of  the  adult 
dose  which  corresponds  to  the  fraction  represented  by  the  child's  ascertained 
body-weight,  as  compared  to  that  of  the  adult,  estimated  at  60-70  kilos,  or 
120-150  pounds.  By  this  method,  the  permissible  dose  for  the  young 
infant  will  hardly  ever  be  exceeded  and  it  may  more  often  fall  below  the 
amount  required  for  a  desired  effect.  Since  the  administration  of  drugs  to 
children  is  usually  confined  to  those  of  definite,  more  or  less  rapid  and 
readily  recognized  action,  and  without  dangerous  qualities,  it  is  often 
better  to  prescribe  medicine  in  divided  doses,  repeating  the  small  dose  until 
the  required  result  by  way  of  bowel  movement,  sleep  production,  disap- 
pearance of  fever,  or  active  perspiration  is  obtained.  The  choice  of  intervals 
between  doses  must,  of  course,  depend  upon  the  rapidity  with  which  the 
result  is  to  be  secured.  With  chloral,  or  acetylsalicylic  acid,  for  instance, 
it  may  vary  between  fifteen  and  thirty  minutes;  with  cathartics  it  may 
range  to  two  or  three  hours.  With  certain  drugs,  it  may  develop  only  after 
a  much  longer  period,  when  smaller  or  less  frequent  doses  than  those  re- 
quired to  produce  the  initial  effect  should  follow.  In  the  use  of  drugs  having 
a  cumulative  effect,  as  with  digitalis,  or  of  those  which  show  a  diminishing 
strength  of  reaction  or  which  lead  to  the  development  of  tolerance,  the  same 
practice  should  be  adopted  with  children  as  in  adults.  A  generally  increased 
sensitiveness  to  only  a  few  drugs  exists  in  childhood.  Opium  belongs  in  this 
class,  as  shown  by  recent  experiments  upon  animals.  It  has  been  already 
said  that  its  injurious  action  is  in  part,  at  least,  due  to  a  misunderstanding  of 
the  indications  for  its  use  or  to  a  failure  to  recognize  the  supposed  symptoms 
of  poisoning  (see  page  115).  Infants  show  an  actual  intolerance  to  phenol; 
and  it  is  well,  therefore,  to  avoid  its  use  altogether  wherever  there  is  a 
possibility  of  its  absorption  in  perceptible  quantities.  Chloroform,  also,  is 
dangerous  for  infants  and  it  is  better  to  use  ether  exclusively  for  purposes  of 
general  anesthesia.  It  is  hardly  necessary  to  add  that  such  poisonous  drugs 
as  cocain  should  be  especially  avoided  in  favor  of  non-poisonous  substitutes. 

The  exhibition  of  medicinal  substances  necessitates  deviations  in  other 
respects  from  the  rules  which  govern  their  prescription  for  adults.  The 
young  infant,  even  if  he  be  not  entirely  without  the  sense  of  taste,  has  that 
function  so  poorly  developed  that  it  is  hardly  ever  necessary  to  disguise  the 
taste  of  drugs.  Even  in  the  second  or  third  year,  children  with  disturbances 
of  nutrition  or  rickets  have  a  sense  of  taste  soslight  that  they  will  take  cod- 
liver  oil  without  objection.  This  statement  needs  the  more  emphasis  because 
advertisements  of  cod-liver  oil  preparations,  wrongfully  claim  that  children 
can  be  made  to  take  the  oil  only  by  force.  If  at  all  necessary,  only  sweet 
substances  are  required  to  disguise  its  taste.  The  taste  for  other  substances, 
as  the  aromatics,  is  normally  wanting.  A  peppermint  lozenge  or  a  piece  of 
chocolate,  given  before  a  medicine  mil  cover  an  objectionable  taste  better 
than  anything  else. 


120  TEXT-BOOK  OF  PEDIATRICS 

Powders  may  be  given  in  milk  or  stirred  into  gruels.  Children  of  five 
or  six  years  will  usually  learn  to  take  them  in  wafers.  Tablets,  pills  and 
capsules,  or  their  contents,  must  be  dissolved  or  crushed  before  the  child 
can  swallow  them. 

Subcutaneous  or  intramuscular  injections  are  made  precisely  as  in  the 
adult.  In  the  infant  it  is  best  to  make  a  subcutaneous  injection  over  the 
breast  and  preferably  in  the  skin  over  the  large  thoracic  muscles,  rather 
than  in  the  extremities.  Intramuscular  injections  are  usually  in  the  glu- 
teal  region. 

Intravenous  infusion  is  very  difficult  or  almost  impossible  in  infants 
and  young  children  because  the  veins  are  not-apparent  beneath  the  skin  and 
are  of  too  small  calibre  to  permit  the  entrance  of  the  canula.  For  injections 
of  small  amounts  of  fluid  one  may  with  practice  use  the  large  veins  of  the 
scalp  (temporal)  and  the  longitudinal  sinus  may  also  be  used.  The  method 
of  subcutaneous  infusion  is  described  on  page  111. 

Among  medicinal  agents  for  external  use  in  infancy,  as  applications  or 
ointments,  of  purely  local  action,  and  but  an  indeterminable  fraction  of 
which  is  absorbed,  concentration  must  be  relatively  high.  It  should  be  at 
least  half  as  great  as  for  the  adult  and  may  be  increased  according  to  need. 
The  greater  delicacy  of  the  infant 's  skin  makes  greater  care  necessary  in  the 
use  of  counterirritants.  This  applies  especially  to  the  frequently  pre- 
scribed tincture  of  iodine. 


SPECIAL  PART. 

I. 
DISEASES  OF  THE  NEW-BORN 

BY 

H.  FINKELSTEIN  and  L.  F.  MEYER, 

Berlin. 

REVISED  BY 

N.  O.  PEARCE,  M.  D., 

Assistant  Professor  of  Pediatrics,  University  of  Minnesota,  Minneapolis. 

THE  viability  of  a  premature  infant  depends  upon  the  degree  of  its 
development  and  the  cause  of  it?  prematurity.  While  disease  in  the  mother 
greatly  reduces  the  chances  of  life  in  the  prematurely  born,  even  though 
carried  almost  to  term,  the  number  and  the  marked  prematurity  of  the 
viable  children  of  healthy  parents  is  surprisingly  great.  It  has  proved 
possible  to  bring  children  born  in  the  sixth  month  of  pregnancy,  weighing 
only  750  gms.  (26  ounces),  and  measuring  35  cm.  (14  inches)  in  length,  to 
normal  development.  It  is  usually  possible  to  maintain  life  in  the  premature 
infant  who  weighs  1200-1500  gms.  (4-5  pounds),  and  is  born  in  the  twenty- 
seventh  or  twenty-eighth  week  of  fetal  life. 

Syphilis  of  the  parent  is  the  most  common  cause  of  premature  birth  and 
impaired  vitality.  In  syphilitic  children  serious  structural  changes  of  the 
visceral  organs  reduce  the  prospect  of  life  to  a  minimum.  Next  to  syphilis, 
such  organic  diseases  as  nephritis,  diabetes,  eclampsia,  tuberculosis,  etc.,  in 
the  mother  are  causally  Important. 

Many  difficulties  are  encountered  in  rearing  premature  infants.  Their 
relatively  great  body  surface  permits  an  increased  loss  of  heat  by  radiation, 
which  must  be  met  by  a  larger  intake  of  energy-producing  food.  This  neces- 
sity is  especially  embarrassing,  for  the  weak  and  torpid  infant,  lying  almost 
lifeless  and  without  appreciable  respiration,  can  be  roused  to  active  nursing 
at  the  breast  with  great  difficulty.  Consequently,  not  a  few  premature  babies 
die  of  starvation.  Agreater  number,  no  doubt,  die  of  disturbances  of  nutrition 
and  intercurrent  infections  to  which  they  can  offer  but  feeble  resistance. 

1.  The  Care  of  the  Premature  Infant. — In  the  treatment  of  the  pre- 
mature child  the  following  points  must  be  considered.  All  chilling  of  the 
body-surface  must  be  avoided,  especially  in  the  fiist  few  days  of  life,  when, 
in  face  of  the  insufficiency  of  the  temperature-regulating  mechanism,  it  may 
cause  marked  lowering  of  the  body  temperature.  The  changing  of  clothing 
or  diapers,  the  bathing  and  feeding  must  all  be  done  rapidly.  The  bath 
should  be  warmer  than  usual,  43  °  C.  (110°  F.)  or,  better,  may  be  omitted 
entirely  at  first.  Artificial  heat  should  be  applied  by  means  of  the  hot  bath, 
as  soon  as  possible,  if  the  premature  infant  has  been  chilled.  A  persisting 

121 


122  TEXT-BOOK  OF  PEDIATRICS 

subnormal  temperature  narrows  the  prospect  of  life.  The  clothing  should  be 
of  the  usual  character.  Wrapping  in  cotton  is  unnecessary. 

Provision  should  be  made  first  of  all  for  continuous  and  uniform  heat 
supply.  The  cheapest  and  most  successful  method,  applied  with  proper 
care,  is  by  the  use  of  hot  water  bottles. 

A  large  roomy  clothes  basket  lined  with  flannel  and  in  which  hot  water 
bottles,  sufficient  to  maintain  the  necessary  basket  temperature,  are  placed, 
is  a  very  efficient  and  easily  prepared  receptacle  for  the  premature  baby. 
The  temperature  should  be  maintained  at  between  80  and  90  degrees  as 
indicated  by  the  temperature  of  the  baby.  This  heat  may  be  regulated  best 
by  partially  covering  over  the  top  of  the  basket  with  a  light  blanket.  It  is 
important  that  the  thermometer  in  the  basket  be  placed  on  the  baby  just 
under  the  outer  clothing  so  that  the  temperature  recorded  will  be  approx- 
imately that  of  the  air  immediately  surrounding  the  baby. 

Four  ordinary  beer  or  mineral  water  bottles  are  filled  with  boiling 
water  and  after  being  well  wrapped  are  laid  in  the  crib  so  that  there  is  one 
bottle  on  each  side,  lying  parallel  to  the  body  and  one  at  each  end.  Over 
these,  heavy  layers  of  bedding  are  placed.  One  of  the  bottles  should  be 
renewed  every  four  hours,  excessive  heat  being  prevented  by  placing  new 
layers  of  bedding  around  it.  The  commercial  U-shaped  containers  or 
ordinary  rubber  hot  water  bottles  are  more  easily  handled  (O.  Rommel). 
The  double-walled  warming  tubs  of  metal  (Crede's  tubs)  which  are  filled 
every  four  hours  with  water  at  50°  C.  (120°  F.)  may  be  used. 

Any  application  of  artificial  heat  requires  careful  handling,  for  injuries 
due  to  either  excessive  or  insufficient  heat  occur  very  easily.  The  incubator 
is  a  more  certain  device  and  less  dependent  upon  the  intelligence  of  attend- 
ants. Various  models  are  in  use  and  some  of  these  are  very  simple  in  con- 
struction. It  is  possible  to  improvise  a  satisfactory  incubator  from  a 
packing  case.  In  the  most  simply  constructed  model,  the  source  of  heat, 
provided  by  hot  bottles  or  stones,  is  in  a  lower  compartment  of  the  box, 
which  is  divided  horizontally;  the  air  entering  through  several  openings  and 
rising,  warming  the  feet  of  the  child  in  the  upper  compartment  and  passing 
out  through  openings  near  the  head. 

For  use  in  clinics,  automatically  regulated  incubators,  susceptible  of 
very  ready  adjustment,  are  designed.  To-day,  in  modern  infants'  hospi- 
tals, entire  rooms  well  ventilated  and  in  which  a  constant  temperature  may 
be  maintained  are  reserved  for  the  new-born.  As  a  rule,  the  incubator 
should  be  regulated  so  that  the  temperature  on  the  inside  is  30°  C.  (86°  F.). 
In  individual  cases,  however,  the  heating  must  be  regulated  according  to 
the  degree  of  heat  demanded  by  the  body-temperature  of  the  child.  There- 
fore, the  child 's  temperature  must  be  taken  very  frequently.  Over-heating 
is  to  be  guarded  against  with  as  much  care  as  is  chilling;  for  aside  from  the 
fever,  serious  disturbances,  (diarrhoea,  convulsions,  collapse),  may  arise  as  a 
result  of  excessive  heat.  An  observing  nurse  will  note  at  once,  from  the 
perspiration  and  the  child 's  restlessness,  that  it  is  too  warm. 

With  increasing  age,  the  functional  capacity  of  the  heat  regulating- 
mechanism  improves,  until  the  child  is  able  to  maintain  an  equal  body-tern- 


DISEASES  OF  THE  NEW-BORN  123 

perature  outside  of  the  incubator.  By  this  time, the  body-weight  is  usually 
2200-2400  gms.  (4-5  pounds).  Naturally,  no  definite  limit  to  the  length  of 
time  for  the  use  of  the  incubator  can  be  set.  External  heat  may  be  neces- 
sary for  a  shorter  period  for  one  child  than  for  another.  Too  great  depend- 
ence upon  the  heat-regulating  ability  of  the  premature  infant  frequently 
results  in  an  arrest  or  loss  of  body-weight  after  the  child  has  been  removed 
from  the  incubator.  Continuation  of  the  external  heat  is  still  essential  to 
its  development. 

Likewise,  it  is  not  possible  to  state  accurately  when  the  child  may  be 
taken  into  the  open  air  for  the  first  time,  despite  of  the  fact  that  sun,  light 
and  ah*  are  important  to  the  infant,  it  is  better  to  wait  until  a  normal 
standard  of  gain  for  its  age  has  been  reached. 

2.  Feeding. — The  premature  infant  has  a  great  task  to  perfoim  during 
its  first  year  of  life,  a  task  which  predicates  vitality  rather  than  weakness. 
While  the  normal  infant  only  doubles  his  body-weight  3410  to  6714  gms. 
(7  to  14  pounds),  by  the  end  of  the  twentieth  week,  the  premature  child, 
according  to  the  observations  of  Camerer,  nearly  triples  his  weight,  1740 
to  5180  gms.  (3^  to  10  pounds),  in  the  same  length  of  time.  This  he  can  ac- 
complish only  with  sufficient  nourishment;  in  fact,  all  observers  have  deter- 
mined that  such  children  elect  to  nurse  very  large  quantities.  They  require 
about  120  to  130  calories  per  kilogram  of  body-weight  (54  to  60  calories  per 
pound),  which  is  from  one-fifth  to  one-third  more  than  normal  children 
demand.  Hence,  the  conclusion  has  been  reached  that  there  is  a  greater 
need  for  nourishment,  conforming  to  Rubner's  law  of  the  ratio  of  food 
requirement  to  the  greater  heat  radiation  resulting  from  the  relatively 
large  surface  of  the  small  infant.  More  recently,  this  assumption  has  been 
denied  and  it  is  asserted  that  the  premature  infant  receives  a  greater 
quantity  than  is  necessary  and  that  his  normal  development  can  be  se- 
cured with  a  much  smaller  supply. 

Most  excellent  results  are  obtained  in  the  premature  infant  by  the  early 
feeding  of  relatively  small  amounts  of  breast-milk  at  four  hour  intervals.  It 
is  especially  true  of  small  and  weak  prematures  that  they  have  a  limited 
ability  to  digest  and  assimilate  food  and  that  their  tolerance  for  food  is 
easily  destroyed  by  ovei  feeding.  An  adequate  gain  in  weight  will  take 
place  on  amounts  of  breast-milk  as  small  as  from  fifteen  to  twenty  cubic 
centimeters  given  every  four  hours.  The  amount  should  be  increased  only 
when  the  weight  remains  stationary  for  forty-eight  hours. 

Breast  feeding  is  more  imperative  for  the  premature  infant  than  for 
any  other;  yet  certain  technical  difficulties  are  met  in  the  attempt  at  natu- 
ral feeding  which  depend  upon  the  limited  power  of  the  child  to  nurse  and 
to  swallow. 

These  difficulties  react  upon  the  child  itself,  in  that  it  gets  too  little 
nourishment  from  the  breast.  Weak  prematures  often  cannot  be  put  to  the 
breast  at  all  and  must  be  given  the  expressed  milk  through  mouth  or  nose,  by 
spoon,  medicine  dropper,tube  or  other  instruments.  Even  stronger  children 
may  overexert  themselves  at  the  breast  and  become  faint;  and  therefore 
are  better  fed  in  the  beginning,  wholly  or  in  part,  with  expressed  milk. 


124  TEXT-BOOK  OF  PEDIATRICS 

On  the  other  hand,  arises  the  difficulty  of  establishing  and  maintaining 
lactation.  The  stimulation  of  powerful  suckling  which  serves  physio- 
logically to  this  end  is  absent  or  inadequate.  Even  though  the  mother  is 
willing  to  nurse  the  infant,  the  secretion  does  not  appear  or  appears  only 
in  small  quantities  and  soon  dries  up.  If  a  wet-nurse  is  employed,  a  con- 
gestion of  milk  in  the  mother's  breast  is  threatened  and  again,  on  this  ac- 
count, the  secretion  may  fail.  The  breast-pump  is  of  some  assistance;  but 
it  is  better  to  substitute  a  strong  healthy  child  at  the  breast  until  the  supply 
increases.  The  wet-nurse  should  be  allowed  to  nurse  her  own  child  at 
times,  or  her  excess  output  should  be  expressed  or  pumped.  It  may  be  well 
for  the  mother  and  the  nurse  to  exchange  children  several  times  a  day. 
Under  these  circumstances,  of  course,  we  must  be  absolutely  certain  that 
syphilis  is  not  present  in  either  the  mother,  the  wet-nurse  or  one  of  the 
children.  A  child  with  lues  or  suspected  of  lues,  on  account  of  the  history 
of  the  parents,  may  always  nurse  its  own  mother,  even  when  she  has 
remained  free  of  syphilitic  manifestations.  But  such  a  child  must  never  be 
put  to  the  breast  of  the  wet-nurse,  although  nothing  can  be  said  against 
feeding  the  infant  with  expressed  milk  provided  by  her. 

Persistent  demand  on  the  breast  is  a  most  important  factor  in  the  estab- 
lishment and  maintenance  of  the  breast-milk  supply  and  even  where 
suckling  is  for  a  time  impossible,  failure  of  the  breast-milk  supply  is  unneces- 
sary, if  the  breasts  are  properly  stimulated  by  correct  and  thorough  man- 
ual expression  of  both  breasts  at  least  five  or  six  times  a  day.  The  best 
method  is  to  grasp  the  breast  one  or  two  centimeters  back  of  the  colored 
areola  and  carry  the  milking  motion  toward  the  nipple,  but  without 
massage.  This  is  to  be  continued  until  the  last  drop  is  obtained.  Mothers 
and  attendants  soon  become  very  expert  in  draining  the  breasts  in  this  man- 
ner, and  the  supply  of  milk  will  be  made  to  increase  rather  than  be  allowed 
to  decrease. 

In  regulating  the  number  of  feedings,  we  must  not  be  influenced,  as  we 
are  in  the  healthy  child,  by  the  fact  that  the  physiologic  food  requirement 
of  the  child  must  be  met,  with  due  respect  to  the  periods  of  waking  and 
sleeping.  Premature  infants  sleep  almost  constantly  and  must  be  aroused 
to  be  fed.  The  artificial  feeding  of  premature  infants  should  be  adopted 
only  in  cases  of  extreme  necessity;  it  is  always  a  risky  undertaking. 

The  life  of  such  a  child,  possessed  of  so  little  reserve  power,  is  seriously 
endangered  by  a  disturbance  of  nutrition.  Every  diarrhoea  that  occurs  in 
the  first  few  weeks  of  its  life  should  serve  as  an  absolute  indication  for  the 
interruption  of  artificial  feeding  and  the  substitution  of  breast-milk. 

It  is  difficult  to  say  what  method  of  artificial  feeding  should  be  chosen  hi 
any  given  case.  All  food  mixtures  have  occasionally  given  good,  but  far 
more  frequently  bad  results.  The  usual  milk  dilutions  do  not  give  the 
acquired  caloric  value.  It  seems  that  buttermilk,  with  the  addition  of 
maltose  and  dextrin  in  carefully  regulated  quantities,  has  great  advantages 
over  the  usual  mixtures  recommended.  Yet,  even  with  this  food,  the 
danger  of  disturbance  is  great. 


DISEASES  OF  THE  NEW-BORN  125 

Prognosis. — A  fairly  large  percentage  of  premature  infants  readily  over- 
come all  of  the  obstacles  to  their  development  and  evidence  greater  vitality 
than  could  be  anticipated  at  birth.  Even  by  the  end  of  the  first  year,  and 
certainly  by  the  close  of  the  second  or  third  year,  their  differences  from  the 
normal  child  are  equalized.  There  are  peculiarities,  however,  which  even 
later  must  be  considered  in  relation  to  premature  birth;  such  as  the  tendency , 
greater  than  in  the  full-term  child,  to  rickets,  spasmophilia  and,  especially 
to  certain  anemic  conditions.  Toward  the  end  of  the  first  year  of  premature 
life,  if  not  earlier,  a  noticeable  pallor  appears,  which  is,  at  least  in  part,  due. 
to  the  insufficient  deposit  of  iron;  which,  as  we  well  know,  accumulates  in 
large  store  during  the  later  months  of  fetal  life.  In  this  event,  the  early 
addition  of  ir on-containing  foods  frequently  produces  favorable  results. 
When  this  is  unsuccessful,  we  have  to  conclude  that  there  is  a  congenital, 
insufficiency  of  function  in  the  blood-forming  tissues. 

It  has  been  said  that  idiocy,  hydrocephalus,  Little 's  disease,  and  other 
central  spastic  paralyses,  are  more  common  in  premature  children  than  in 
others.  This  seems  to  be  true,  but  their  causation  is  not  to  be  charged  to  the 
fact  of  premature  birth  in  itself,  but  rather  to  the  conditions  of  disease  in  the 
parents  which  caused  the  premature  birth  and  are  also  responsible  for  these 
anomalies  of  the  nervous  system.  Premature  children  of  healthy  parents 
can  hardly  be  said  to  have  a  poorer  prognosis,1  in  regard  to  these  compli- 
cations, than  children  born  at  term. 

ASPHYXIA 

By  asphyxia,  is  understood  a  condition  produced  by  interference  with 
the  oxygen  intake  and  the  carbon  dioxide  output  of  the  child.  This  inter- 
ference may  have  developed  while  the  child  is  still  within  the  uterus,  so  that 
it  is  born  asphyctic,  or  it  may  arise  after  birth. 

1.  Congenital  Asphyxia. — It  is  a  recognized  fact  that  the  stimulus  to 
the  first  inspiration  is  given  to  the  respiratory  centre  by  an  excess  of  carbon 
dioxide  and  an  insufficiency  of  oxygen  in  the  blood,  as  a  twin  result  of 
interruption  of  the  placental  circulation.    If  this  interruption  happens  before 
the  delivery  of  the  child's  head,  respiratory  movements  will  occur  too  early, 
and  may  cause  the  asphyxia.    Disturbances  of  the  circulation  between  the 
mother  and  child  may  be  occasioned  by  premature  separation  of  the  pla- 
centa, by  compression  of  the  umbilical  cord,  etc. 

Symptoms. — Two  types  of  asphyxia  are  clinically  distinguishable.  1 .  The 
slightly  asphyctic  child  is  born  with  a  deep  bluish-red  color  (asphyxia 
livida)  with  slow  heart  action,  developing  slight  respiratory  movements  or 
even  apncea,  but  of  good  muscular  tone.  Active  respiration  is  easily  pro- 
duced in  this  child  by  stimulation  of  the  skin  reflexes. 

2.  The  severely  asphyctic  child  with  a  skin  color  resembling  death- 
pallor,  (asphyxia  pallida),  in  whom  all  reflexes  and  all  muscle  tone  have 
disappeared.    A  very  weak  heart  action  alone  shows  that  life  is  still  present. 

1  The  bulging  of  the  fontanelle,  which  frequently  occurs  in  premature  children  dur- 
ing the  second  half  year,  is  of  no  particular  prognostic  value.  As  a  rule,  the  slight 
hydrocephalus,  which  appears  in  connection  with  the  rapid  growth  of  the  brain,  dis- 
appears in  a  few  months. 


126  TEXT-BOOK  OF  PEDIATRICS 

The  attempted  respiration  has  ceased  and  cannot  be  awakened  by  the  usual 
skin  stimulation. 

At  autopsy  the  signs  of  suffocation  are  seen  in  congestion  of  the  viscera, 
hemorrhage  from  the  serous  membranes  and,  as  result  of  the  premature 
breathing,  meconium  and  amnionic  fluid  in  the  air  passages. 

Prognosis. — The  prognosis  is  favorable  in  the  milder  form  and  doubtful 
in  the  severe  form.  Even  in  the  latter,  the  seemingly  impossible  may 
sometimes  be  accomplished  by  proper  methods.  The  claim  has  been  made 
.that  the  survivors  of  asphyxia  are  predisposed  to  diseases  of  the  central 
nervous  system,  (Little's  disease  and  idiocy),  but  this  has  not  been  proved. 
Doubtless,  some  inherent  predisposition  of  the  central  nervous  system 
must  be  present  when  asphyxia  has  such  marked  sequela?. 

The  recent  work  of  Rodda  and  others  on  the  hemorrhagic  disease  of  the 
new-born  throws  much  light  upon  this  subject.  It  is  now  generally  recog- 
nized that  severely  asphyxiated  infants  are  most  likely  to  suffer  from 
cerebral  hemorrhage,  which  we  believe  to  be  largely  responsible  for  the 
subsequent  paralysis  and  mental  deficiency. 

Therapy. — The  most  efficient  means  of  stimulating  the  respiration  is 
through  frequent  and  powerful  irritation  of  the  skin.  After  the  aspirated 
material  has  been  removed  from  the  mouth  and  pharynx  by  means  of  a 
catheter,  the  new-born  should  be  quickly  bathed  in  warm  water  and  rubbed 
thoroughly  dry.  If  this  does  not  produce  results,  the  child  should  be  plunged 
into  cold  and  then  immediately  into  warm  water;  a  double  bowl  bath. 
These  methods  are  usually  successful  in  the  milder  form  of  asphyxia. 

In  the  severer  form,  more  energetic  measures  must  be  adopted.  First  of 
all,  the  Schultze's  method  of  resuscitation,  described  in  obstetrical  works,  the 
great  value  of  which  is  generally  recognized,  is  advised.  In  addition,  com- 
pression of  the  thorax,  heart-massage,  at  the  rate  of  thirty  strokes  a  minute, 
and  rhythmic  traction  and  release  of  the  tongue,  some  forty  or  fifty  times 
a  minute,  may  be  tried. 

2.  Postnatal  Acquired  Asphyxia. — When  asphyxia  develops  after  birth, 
it  is  due  either  to  disease  of  the  central  nervous  system  or  to  some  disorder 
of  the  circulatory  or  respiratory  mechanism  which  interferes  with  the  normal 
supply  of  oxygen. 

Such  a  condition  actually  develops  in  pulmonary  disease,  in  the  white 
pneumonia  of  syphilis  and  enteritis;  in  heart  lesions;  in  malformations, 
(pulmonary  aplasia,  diaphragmatic  hernia,  compression  of  the  trachea  by 
goitre  or  hyperplastic  thymus) ;  in  general  diseases  of  the  new-born,  (lues, 
sepsis) ;  in  diseases  or  injuries  of  the  brain  (encephalitis,  congenital  hydro- 
cephalus,  brain  hemorrhage  from  birth  trauma) ;  and  in  weak  premature  in- 
fants in  whom  it  is  usually  combined  with  pulmonary  atelectasis  dependant 
upon  imperfect  thoracic  expansion.  Such  asphyxia  occurs  soon  after  birth. 
If  a  child  who  has  developed  well  during  the  early  weeks,  suddenly  falls  sub- 
ject to  asphyctic  attacks,  the  disturbance  of  the  respiiation  is  usually  due  to 
a  grippe-like  infection.  In  premature  children  and  in  those  with  severe 
disturbance  of  nutrition,  spontaneous  asphyctic  seizures  occur,  the  cause  of 
which  has  never  been  definitely  explained. 


DISEASES  OF  THE  NEW-BORN  127 

Symptoms. — The  clinical  picture  differs  with  the  disease  which  causes 
the  asphyxia.  The  inspirations  are  infrequent,  gasping,  occur  in  irregular 
sequence  or  are  interspersed  with  long  pauses  during  which  they  are 
entirely  absent.  The  skin  is  blue  and  cyanotic,  the  body-temperature  is 
subnormal,  the  extremities  are  cold  and  occasionally  a  slight  edema  is  seen. 
Fine  crackling  rales  are  heard,  from  time  to  time,  over  the  lungs  as  a  result 
of  the  atelectatic  process. 

In  forms  of  asphyxia  which  develop  late,  symptoms  are  usually  pres- 
ent, such  as  fever,  cough,  retraction  of  the  epigastrium  and  intercostal 
spaces,  which  even  with  negative  lung  findings  indicate  a  catarrhal  pulmo- 
nary disease. 

Diagnosis. — In  the  diagnosis  the  cause  must  always  be  looked  for  first, 
because  the  asphyxia  itself  is  no  more  than  a  symptom. 

Very  frequently  some  developmental  error  which  was  not  and  could  not 
be  discovered  during  life  is  first  seen  at  autopsy.  In  other  cases,  the  findings 
are  those  of  atelectasis,  with  the  conditions  described  in  the  intra-uterine 
form  of  asphyxia. 

Prognosis. — The  prognosis  depends  entirely  upon  the  cause.  The 
anomalies  named  naturally  give  but  a  poor  outlook.  Lacking  these,  how- 
ever, the  prognosis  depends  largely  upon  the  possibilities  of  treatment 
and  care  and  even  then  the  desired  result  may  not  be  attained. 

Treatment. — As  in  the  congenital  form,  rapid  alternation  from  the  hot 
to  the  cold  bath,  friction  of  the  skin  and  Schultze's  method  may  be  tried. 
The  be?t  method  of  all  is  the  inhalation  of  oxygen. 

In  premature  infants  born  with  asphyctic  tendencies,  all  causes  of  rapid 
cooling  of  the  body  must  be  avoided  and  special  attention  must  be  given  to 
the  supply  of  a  sufficient  quantity  of  food. 

BIRTH  TRAUMATA 

EXTERNAL  CEPHALHEMATOMA 

Symptoms. — Cephalhematoma  is  the  term  applied  to  a  hemorrhage  oc- 
curring on  the  second  or  third  day  and  occasionally  later,  over  the  parietal 
bone  or,  more  rarely,  over  other  cranial  bones.  Now  and  then  it  is  bilateral 
and  reaches  its  maximal  size  during  the  fifth  or  sixth  day  (Figure  23) .  The 
swelling  rarely  exceeds  the  size  of  an  egg;  larger  tumors  are  exceptional.  It  is 
not  sensitive  to  pressure.  Upon  palpation,  a  hard  boundary  line  is  felt  inside 
of  which  the  palpating  finger  seems  to  touch  upon  a  soft  dough-like  hollow. 

During  the  following  weeks,  the  extravasate  is  gradually  resorbed  and  the 
periosteum  again  becomes  adherent  to  the  bone  and  presents  a  thickened 
surface  which  remains  for  a  long  time.  If  the  resorption  occurs  slowly,  a 
thin  plate  of  bone  is  formed  over  the  tumor  from  the  lifted  periosteum,  which 
is  recognized  upon  palpation  by  its  peculiar  parchment-like  rattle.  The 
general  well-being  of  the  infant  is  not  disturbed  and  the  body-temperature 
is  not  influenced,  excepting  as  a  result  of  interference  or  of  spontaneous 
infection,  inflammation  and  pus  formation. 

Etiology. — The  probable  and  generally  accepted  theory  is  that  the  scalp 
is  displaced  by  pressure  against  the  walls  of  the  parturient  canal  during 


128  TEXT-BOOK  OF  PEDIATRICS 

delivery,  so  that  the  periosteum,  which  is  not  so  closely  adherent  to  the 
bone  in  the  new-born  as  in  later  life,  is  loosened.  On  account  of  its  delicate 
vascularity,  hemorrhage  between  the  periosteum  and  the  bone  occurs.  The 
loosening  of  the  periosteum  at  the  sutures  is  impossible,  because  here  the 
pericranium  is  more  closely  adherent  to  the  surface  of  the  skull,  a  circum- 
stance which  limits  the  hematoma  to  the  site  of  the  one  cranial  bone. 
Other  attempts  at  explanation,  such  as  defects  of  ossification,  decom- 
pression of  the  head  with  a  resulting  hyperemia  and  rupture  of  vessels,  are 
less  plausible. 

One  must  not  fail  to  investigate  the  coagulation  and  bleeding  time  at 


FIG.  23. — Cephalhematoma  over  left  parietal  bone  (Gisela  Children's 
Hospital,  Munich,  Prof.  Ibrahim). 

frequent  intervals  when  a  cephalhematoma  is  present  as  it  has  been  repeat- 
.edly  shown  to  be  coincident  with  the  development  of  general  hemorrhagic 
disease  of  the  new-born. 

Diagnosis. — The  diagnosis  should  give  no  difficulty.  The  inexperienced 
observer  will  occasionally  be  deceived  by  the  surrounding  bony  wall  and  will 
mistakenly  suppose  that  he  has  to  do  with  a  defect  of  the  cranial  vault  with 
a  resulting  meningocele.  A  cephalhematoma  can  always  be  distinguished 
from  a  meningocele  by  its  location.  While  the  meningocele  usually  appears 
at  a  suture  or  a  fontanelle,  the  hematoma  commonly  covers  the  arch  of  the 
bone.  Pulsation  of  the  tumor,  its  increase  in  size  when  the  child  cries,  and 
the  possibility  of  its  replacement,  are  all  indicative  of  meningocelle  rather 
than  of  hematoma. 


DISEASES  OF  THE  NEW-BORN  129 

From  the  unimportant  swelling  of  the  scalp,  the  caput  succedaneum,  a 
diffuse  edema  of  the  soft  parts  which  may  be  present  even  at  birth  and  which 
soon  disappears,  the  cephalhematoma  is  distinguished  by  its  limitation  to 
one  cranial  bone. 

Prognosis. — The  prognosis  is  good  provided  that  infection  is  avoided. 
In  the  latter  case,  it  becomes  doubtful;  for  bone  caries,  meningitis  and  sepsis 
may  threaten  the  life  of  the  child  if  the  pus  is  not  immediately  evacuated. 

Treatment. — Usually  treatment  is  not  necessary  when  the  process  runs 
its  natural  course.  Because  of  the  danger  of  infection,  it  is  best  to  await 
spontaneous  recovery.  Only  when  the  resorption  of  the  extravasate  takes 
too  long,  may  aseptic  puncture  be  required.  When  symptoms  of  an 
infection  occur,  i.  e.,  redness  of  the  skin,  fever,  etc.,  surgical  interference 
is  necessary. 

INTERNAL  CEPHALHEMATOMA 

In  very  rare  cases,  hemorrhage  between  the  cranial  bones  and  the  dura 
mater  occurs  simultaneously  with  the  external  hemorrhage.  This  is  termed 
internal  cephalhematoma.  This  will  occur,  however,  only  when  a  fracture, 
from  birth  trauma,  is  present  or  when  an  external  extravasate  passes 
through  the  skull  by  way  of  some  ossification  defect  in  the  frontal  or  occi- 
pital bone.  Symptoms  of  cerebral  pressure  indicate  the  nature  of  the  trouble. 
It  may  be  distinguished  from  those  manifestations  of  cerebral  pressure 
which  are  caused  by  hemorrhage  in  the  meninges  or  in  the  brain  by  the 
absence  of  blood  in  the  fluid  obtained  by  lumbar  puncture. 

The  prognosis  of  an  epidural  hemorrhage  is  doubtful.  With  symptoms 
of  cerebral  pressure,  the  aspiration  of  the  extravasate  may  be  necessary 
after  its  location  has  been  determined  by  exploratory  puncture. 

CEREBRAL  HEMORRHAGE 

In  difficult  instrumental  labors  and  rarely  in  normal  labors  so  great  a 
compression  may  be  produced  that  evidences  of  cerebral  pressure  occur. 
Such  children  are  born  asphyctic,  the  respiratory  action  is  weak  and  irreg- 
ular, the  pulse  is  slow.  If  the  asphyxia  does  not  yield  to  proper  treatment 
and  if  convulsions  and  paralyses  also  appear,  it  is  improbable  that  the 
condition  is  caused  by  pressure  alone  and  cerebral  hemorrhages  must 
be  considered. 

Etiology. — The  trauma  which  causes  the  hemorrhage  does  not  necessarily 
cause  severe  deformities,  fissures,  or  fractures  of  the  cranium.  Frequently 
hemorrhage  occurs  without  external  injury  and  this  even  when  the  deliv- 
ery was  not  particularly  difficult.  The  cause  is  rather  to  be  found  in  an 
overlapping  of  the  cranial  bones  with  a  resulting  congestion,  rupture  of  the 
vessels,  etc. 

Recent  work  on  hemorrhagic  disease  of  the  new-born  leads  us  to  believe 
that  a  very  large  percentage  of  cases  of  cerebral  hemorrhage  are  due  to  this 
disease  rather  than  to  traumatism  as  indicated  by  the  author. 

Symptoms. — The  clinical  picture  is  caused  by  the  excessive  intradural 
pressure.  Sopor,  slow  pulse,  irregular  or  intermittent  respiration,  a  bulging 
9 


130  TEXT-BOOK  OF  PEDIATRICS 

of  very  tense  fontanelle,  strabismus,  paralyses  and  especially  convulsions 
will  be  observed.  The  deep  and  continuous  sleep,  the  sopor,  and  the  im- 
perfect respiration,  in  cases  in  which  postnatal  asphyxia  is  increased  rather 
than  improved  by  the  usual  methods  of  treatment,  justify  the  suspicion  of 
cerebral  hemorrhage. 

In  favorable  cases,  even  serious  cerebral  symptoms  disappear,  after 
several  days,  without  leaving  a  trace  of  a  brain  lesion.  Quite  frequently, 
however,  epileptiform  convulsions  or  paralyses  develop  earlier  or  later  as 
evidences  of  permanent  cerebral  injury. 

At  autopsy,  in  those  children  who  die  with  symptoms  of  severe  asphyxia, 
we  find  subdural  or  subarachnoid  hematoma  on  the  convexity  of  the  brain. 
Hemorrhages  over  the  cerebellum  are  more  rare,  as  are  those  at  the  base  and 
in  the  ventricles.  Hemorrhages  into  the  brain  substance  are  exceptional 
but  probably  occur  more  frequently  than  is  generally  believed.  They 
are  usually  very  minute  in  character  and  only  discovered  at  autopsy  by 
microscopical  examination,  or,  in  case  of  recovery,  are  either  completely 
absorbed — giving  no  subsequent  symptoms  or  are  a  large  factor  in  the  later 
development  of  so-called  "Little's  Disease." 

Diagnosis. — The  differentiation  of  hemorrhage  from  malformation  of 
the  brain,  especially  when  visible  injuries  are  absent,  is  very  difficult.  In 
doubtful  cases  lumbar  puncture  is  advisable.  Cerebrospinal  fluid  con- 
taining blood,  with  a  large  number  of  broken  down  or  crenated  red  blood- 
cells,  is  evidence  favoring  a  diagnosis  of  cerebral  hemorrhage.  Much 
information  may  be  obtained  from  a  test  of  the  coagulation  and  bleeding 
time  in  cases  of  suspected  cerebral  hemorrhage.  A  delayed  coagulation  and 
bleeding  time  combined  with  the  symptoms  of  cerebral  hemorrhage  makes 
the  diagnosis  almost  certain,  and  points  to  the  immediate  necessity  of 
subcutaneous  injections  of  whole  blood. 

Prognosis. — The  prognosis  should  always  be  made  reservedly,  even  if 
all  manifestations  of  intracranial  pressure  disappear  within  a  few  days. 
The  danger  of  some  permanent  effect  upon  cerebral  function  remains. 
Paralyses,  idiocy  and  epilepsy  are  not  infrequently  the  late  sequelae  of  such 
a  lesion.  With  symptoms  of  great  pressure,  the  attempt  to  puncture  and  to 
aspirate  the  extravasate  may  be  considered. 

HEMATOMA  OF  THE  STERNOCLEIDOMASTOID 

As  a  result  of  rupture  of  the  fibres  of  the  neck  muscles,  especially  the 
sternomastoid,  the  trapezius,  or  the  scaleni,  hemorrhage  into  the  muscular 
sheath  occurs.  Such  ruptures  may  occur  as  easily  in  spontaneous  labor  as  in 
artificial  birth.  An  extreme  rotation  of  the  head  is  enough  to  cause  such  an 
injury  to  the  muscle.  Symptomatically  we  notice,  soon  after  birth,  a  small 
swelling  of  about  the  size  of  a  pigeon's  egg  on  the  neck.  This  swelling  is 
hard,  is  not  painful  and  is  covered  by  intact  skin. 

The  hematoma  of  the  muscle  and  the  scar  formation  which  follows  the 
absorption  of  the  blood  must  be  distinguished  from  a  form  of  cicatrization 
acquired  in  intra-uterine  life,  which  is  probably  a  more  common  cause  of 
wry-neck  than  this  injury. 


DISEASES  OF  THE  NEW-BORN 


131 


Therapy. — Since  the  hematoma  is,  as  a  rule,  resorbed  spontaneously 
within  a  few  weeks,  gentle  massage  and  passive  motion  are  to  be  advised. 
However,  the  possibility  of  a  contracture  of  the  muscle  developing  as  an 
after-result  of  the  hematoma  with  the  resultant  wry-neck  (caput  obstipum) 
should  not  be  overlooked. 

PARALYSES 

(a)  Paralysis  of  the  Brachial  Plexus. — This  form  of  paralysis  in  the  new- 
born is  the  result  of  pressure  upon  or  rupture  of  the  nerve  plexus  in  normal 
labor  and  more  frequently  in  instrumental  delivery. 

It  will  be  remembered  that  the  brachial  plexus  consists  of  a  combination 
of  branches  of  the  cervical  nerves  from 
the  fifth  to  the  eighth,  with  the  first 
thoracic.  It  supplies  the  muscles  of 
the  shoulder,  the  arm  and  the  forearm. 
Injury  to  the  plexus  occurs  most  fre- 
quently at  Erb  's  point,  which  lies  two 
to  three  centimeters  above  the  clav- 
icle. Electric  stimulation  at  this  point 
produces  contraction  of  the  deltoid, 
the  triceps,  the  biceps,  the  brachio- 
radialis,  the  supinators  and  the  infra- 
spinatus  muscles.  Accordingly,  the 
paralysis  is  usually  of  the  so-called 
Erb's  type,  affecting  the  muscle  groups 
named,  but  not  disturbing  sensation. 

Symptoms.  —  Immediately  after 
birth,  the  arm  lies  immovable  and  lax 
and  is  rotated  inward.  The  palm  of 
'the  hand  is  directed  outward  and 
backward.  Reflex  movement,  by  flex- 
ion of  the  arm  cannot  be  elicited  by 
pin  pricks,  to  which  the  normal  arm 
readily  responds.  The  paralysis  is 
especially  noticeable  when  the  child 
is  lifted  up,  the  paralyzed  member  hanging  relaxed  by  its  side  (Figure  24). 

A  second  type  of  birth  paralysis,  the  so-called  paralysis  of  the  forearm, 
is  more  rare.  In  this  form,  the  muscles  supplied  by  the  seventh  and  eighth 
cervical  and  the  first  thoracic  nerves  are  affected.  This  involves  a  paralysis 
of  the  forearm,  the  smaller  muscles  of  the  hand,  and  the  flexors  and  exten- 
sors of  the  fingers.  It  may  be  accompanied  by  disturbances  of  sensation. 
Some  cases  also  show  manifestations  of  Klumpke's  paralysis,  oculopupil- 
lary  symptoms,  contracted  pupil,  narrowed  palpebral  fissure  and  retraction 
of  the  bulb.  Frequently  the  muscles  concerned  in  the  first  type  are  involved 
also  in  these  cases  and  the  paralysis  may  be  equally  distributed  in  the  arm 
and  forearm  (Figure  25). 


FIG.    24. — Birth  paralysis  of  the  arm,  upper 
arm  type. 


132 


TEXT-BOOK  OF  PEDIATRICS 


After  the  paralysis  has  existed  for  some  time,  the  muscles  give  the 
reaction  of  degeneration.  Atrophy,  flail-joint  and  contractures  ensue. 

The  pathologic  findings  in  children  dying  from  concurrent  diseases,  who 
have  come  to  autopsy,  show  hematomatas,  tears,  and  the  presence  of 
scar-tissue  in  the  brachial  plexus. 

Diagnosis. — The  diagnosis  of  birth  paralyses  is  difficult,  especially  in 
their  differentiation  from  fractures  and  luxations  occurring  during  delivery 
which  are  often  characterized  by  similar  disturbances  of  mobility.  Sepa- 
ration of  the  epiphysis  at  the  head  of  the  humerus  is  especially  important. 


FIG.  25. — Birth  paralysis,  rupture 
of  chords  of  cervial  plexus. 


FIG.  26. — Left  sided  unilateral  birth  paralysis 
of  the  facial  nerve  (Berlin  Children's  Asylum). 


Paralysis  and  fractures  occasionally  occur  together.  Error  in  diagnosis  may 
be  avoided  by  careful  palpation  and  by  an  X-ray  picture  of  the  fracture  or 
dislocation.  Changes  in  the  contour  of  the  shoulder,  as  seen  from  above, 
should  lead  to  a  suspicion  of  dislocation.  Hyperpronation  and  early  con- 
tractures are  similarly  indicative.  Careful  general  examination  and  the 
Wassermann  reaction,  will  prevent  confusion  with  luetic  pseudoparalysis 
(Parrot's  paralysis;  see  Syphilis). 

Recovery  usually  occurs  in  paralysis  of  the  arm.  Complete  restoration 
of  function  is  very  frequent  and  in  mild  cases  results  within  a  few  weeks; 
but  it  must  not  be  expected  with  any  too  great  certainty.  In  the  forearm 
type  and  in  complete  paralysis,  the  prognosis  is  much  less  favorable.  If  no 


DISEASES  OF  THE  NEW-BORN  133 

improvement  or  but  partial  recovery  takes  place  by  the  fourth  month,  there 
is  nothing  more  to  be  hoped  for. 

Treatment. — The  treatment  should  attempt  to  prevent  atrophy  and 
contracturc.  At  first,  gentle  massage  and  passive  movements  are  indicated. 
Later,  faradization  and  galvanization  may  be  used  two  or  three  times  a 
week.  If  paralysis  remains,  recent  experience  has  shown  that  operative 
interference  (sutuie  of  nerve  trunks,  separation  of  adhesions,  or  tendon 
transplantation),  may  be  efficacious. 

(6)  Facial  Paralysis. — Facial  paralysis  is  frequently  a  result  of  birth 
injury. 

The  cause  must  be  sought  in  trauma  to  the  peripheral  route  of  the  facial 
nerve.  Paralysis  of  the  facialis  is  three  times  as  common  in  cases  of  forceps 
delivery  as  in  spontaneous  birth,  doubtless  because  of  the  direct  pressure  of 
the  forceps  upon  the  nerve.  However,  the  pressure  upon  irregularities  of  the 
pelvic  outlet,  especially  in  contracted  pelvis,  must  be  considered. 

The  symptoms  are  those  generally  seen  in  facial  paralysis.  In  the  act  of 
crying,  the  mouth  is  drawn  toward  the  normal  side  (Fig.  26)  and  frequently 
the  eye  on  the  palsied  side  cannot  be  completely  closed.  The  paralysis  is 
commonly  unilateral.  In  diagnosis,  a  congenital  nerve  defect  or  peripheral 
or  central  site  must  be  excluded.  A  double  paralysis  is  peculiarly  suggestive 
of  this  cause. 

The  prognosis  is  generally  favorable.  In  most  cases  the  palsy  disap- 
pears within  a  few  days;  or,  in  slower  process,  by  the  end  of  six  weeks. 
Continued  paralysis  is  rare  and  always  arouses  a  suspicion  of  a  more  re- 
mote etiology. 

The  treatment  consists  of  faradization  with  weak  currents.  It  should  be 
used  only  if  the  paralysis  shows  no  improvement  within  two  or  three  weeks. 

DISEASES  OF  THE  UMBILICUS 

During  fetal  life,  the  umbilical  cord  forms  the  connection  between  the 
mother  and  the  fetus.  It  contains,  besides  the  remnants  of  embryonic 
organs  (the  yolk-stalk  and  the  allantois),  two  arteries  and  a  vein  covered 
by  the  amnion  and  imbedded  in  Wharton  's  jelly.  The  anatomic  structure  of 
these  channels  differs  from  that  of  other  vessels.  The  walls  are  thick,  and 
well  supplied  with  muscle  fibres  and  elastic  tissue.  They  contain  no  vasa 
vasorum,  so  important  for  the  nutrition  of  the  vessels  themselves.  The 
blood  from  the  placenta  passes  through  the  umbilical  vein  to  the  body  of 
the  child.  Here  the  vein  divides  into  two  branches,  one  of  which  passed 
into  the  portal  vein,  while  the  other,  the  ductus  venosus  arantii,  opens 
directly  into  the  inferior  vena  cava.  The  blood  passes  through  the  fetal 
circulation  and  is  finally  carried  back  to  the  placenta  by  the  umbilical 
arteries  which  arise  from  the  hypogastric  vessels. 

The  circulation  of  the  umbilical  vessels  stops  when  the  first  respirations 
occur.  On  account  of  the  opening  up  of  the  lungs  the  umbilical  blood-pres- 
sure falls,  the  arteries  and  the  veins  contract  by  means  of  the  large  amount 
of  elastic  tissue  present  in  their  walls  and  force  out  the  remaining  blood. 


134  TEXT-BOOK  OF  PEDIATRICS 

Because  of  the  absence  of  the  vasa  vasorum  and  therefore  of  all  nutritive 
supply,  the  umbilical  cord  dries  up.  This  mummification  cannot  be  con- 
sidered a  vital  phenomenon,  as  it  was  once  believed  to  be.  It  follows  even 
when  the  stump  is  separated  from  the  body  of  the  child  and  is  kept  warm 
and  dry.  Warmth  and  moisture,  on  the  other  hand,  produce  decay  of  the 
stump.  The  physiologic  drying  is  usually  completed  by  the  fourth  day. 
Coincident  with  it,  a  circumscribed  inflammation  at  the  navel  occurs  which 
causes  the  separation  of  the  stump,  usually  on  the  fifth  or  sixth  day.  The 
umbilical  wound  lies  deeper  than  the  walls  of  the  abdomen,  in  a  small  funnel- 
shaped  depression  formed  by  the  retraction  of  the  intra-abdominal  portion 
of  the  umbilical  vessels.  A  period  of  about  three  weeks  is  necessary  for 
the  healing  of  the  wound. 

As  results  of  the  cessation  of  the  blood  flow,  thrombi  immediately  form 
in  the  intra-abdominal  portion  of  the  umbilical  vessels.  These  thrombi  are 
gradually  organized  by  the  growth  of  connective  tissue  from  the  intima 
until  the  vessels  are  completely  closed  (endarteritis  obliterans).  The  um- 
bilical vein  becomes  the  ligamentum  teres  extending  from  the  umbilicus  to 
the  liver;  the  arteries  become  the  lateral  vesico  umbilical  ligaments,  which 
pass  from  the  navel  to  the  urinary  bladder. 

CONGENITAL  ANOMALIES 

The  skin  navel  (critical  navel)  is  formed  by  the  extension  of  the  skin  from 
the  body  over  the  cord,  so  that  after  the  cord  has  fallen  off  the  usual  funnel- 
shaped  depression  is  absent.  The  umbilical  wound  lies  at  the  apex  of  a 
protrusion  which,  in  most  cases,  is  gradually  retracted,  but  which  may  re- 
main permanently. 

The  amiiion  navel,  on  the  contrary,  is  caused  by  the  spreading  of  the 
amnionic  sheath  of  the  cord  which  is  normally  connected  to  the  skin  at  the 
base  of  the  cord.  This  may  spread  to  the  size  of  a  dollar  over  the  abdominal 
surface.  The  mummification  and  falling  off  of  the  cord  leaves  a  skin  defect 
over  this  area,  which  usually  heals  by  granulation.  Both  these  anomalies 
are  harmless  and  require  no  special  treatment. 

Hernia  at  the  umbilical  cord  (funicular  umbilical  hernia],  is  more 
important.  Its  origin  is  to  be  traced  to  the  normal  umbilical  hernia  which 
persists  to  the  second  month  of  fetal  life.  A  loop  of  intestine  which  should 
normally  return  to  the  abdominal  cavity  has  remained  enclosed  within  the 
sheath  of  the  umbilical  cord.  A  large  tumor  forms  at  the  umbilical  site. 
The  covering  of  the  tumor  is  so  transparent  that  the  contents  may  be  seen, 
through  it.  The  hernia  often  contains  other  organs  than  the  intestine. 

The  stomach,  liver  or  spleen  have  occasionally  been  seen  through  it. 
Only  rarely  is  the  rupture  spontaneously  healed.  If  the  condition  is  not 
treated,  a  fatal  peritonitis  may  set  in  after  the  cord  has  separated. 

Error  in  diagnosis  is  possible  in  the  case  of  small  ruptures  only.  It  is 
especially  dangerous,  because  where  the  intestine  has  been  tied  off,  gangrene 
and  ileus  cannot  be  avoided.  It  is  necessary,  therefore,  to  establish  the 
content  of  the  umbilical  hernia  by  careful  palpation. 


DISEASES  OF  THE  NEW-BORN  135 

The  treatment  consists,  generally,  in  prompt  laparotomy,  reposition 
and  suture  of  the  edges  of  the  skin.  Only  in  rare  cases  should  any  depend- 
ence be  placed  upon  spontaneous  healing;  it  has  rarely  been  observed. 

Persistence  of  the  Omphalomesenteric  Duct. — The  omphalomesenteric 
duct,  which  passes  from  the  intestine  to  the.  yolk  sac,  is  normally  obliter- 
ated by  the  end  of  the^second  month  of  fetal  life.  If  this  does  not  occur,  a 
communication  between  the  ileum  and  the  umbilicus  remains — a  patent 
Meckel  's  diverticulum. 

This  rare  anomaly  prevents  the  healing  of  the  umbilical  wound  after 
the  cord  has  separated.  A  secretion  appears  and  close  examination  reveals  a 
fistula  from  which  a  turbid  fluid  exudes.  This  fluid,  upon  investigation 
proves,  by  its  odor  and  its  microscopic  and  chemical  features,  to  be  intes- 
tinal content.  Diverticulae  also  occur,  which  have  been  obliterated  upon 
the  intestinal  side,  but  remain  open  at  the  umbilicus  and  which  secrete  small 
amounts  of  an  alkalin  fluid  resembling  intestinal  juice. 

The  treatment  consists  in  the  surgical  removal  of  the  diverticulum. 

Fistula  due  to  persistence  of  the  urachus.  Normally  the  urinary  bladder 
is  developed  from  the  urachus,  while  the  remainder  of  the  organ  obliterates 
and  forms  the  median  vesical  ligament.  If  this  latter  portion  remains  patent 
as  it  does  in  rare  cases,  a  communication  between  the  bladder  and  the  umbil- 
icus is  established  with  consequent  leakage  of  urine  from  the  fistula  at  the 
navel.  The  fluid  may  be  recognized  by  the  presence  of  uric  acid. 

Etiologically  this  malformation  depends  upon  obstruction  to  the  pas- 
sage of  the  urine  from  the  bladder,  by  normal  means  such  as  phimosis, 
preputial  adhesions,  etc. 

In  the  treatment,  the  existence  of  obstructions  must  be  sought  for.  The 
fistula  should  be  cauterized  after  the  natural  urinary  passages  have  been 
opened.  In  some  cases,  the  edges  must  be  freshened  and  sutured. 

INFECTIONS  OF  THE  UMBILICUS 

Any  delay  in  the  separation  of  the  umbilical  stump  and  in  the  healing 
of  the  wound  (see  page  133)  should  direct  our  suspicion  to  a  possible  infection 
of  the  wound,  complicating  the  physiologic  process.  The  distinction  be- 
tween the  normal  and  the  diseased  umbilical  wound  cannot  be  too  sharply 
drawn.  Practically,  the  wound  should  be  considered  infected  whenever 
inflammation  appears  and  the  temperature  rises  after  the  stump  has 
sloughed.  The  infection  which  is  usually  due  to  cocci,  more  rarely  to 
bacilli,  is  localized  in  the  stump  or  in  the  umbilical  wound  or  may  extend 
from  either.  Apparently  normal  healing  does  not  predicate  the  absence  of 
infection;  for  serious  extensive  infections  often  occur  without  the  usual 
visible  signs  of  inflammation. 

According  to  location,  we  may  classify  the  diseases  of  the  umbilical 
stump,  e.g.,  irregularity  of  physiologic  mummification,  gangrene,  etc.; 
localized  inflammation  of  the  umbilicus,  as  blennorrhea,  ulcer,  fungus, 
omphalitis,  gangrene  of  the  umbilicus;  and  finally  general  infections  starting 


136  TEXT-BOOK  OF  PEDIATRICS 

from  this  focus  as  arterial  thrombosis,  periarteritis,  venous  thrombosis, 
and  periphlebitis. 

Another  classification  in  common  use  is  dictated  by  the  severity  of  the 
disease.  It  distinguishes: 

MILD  DISEASES  OF  THE  UMBILICAL  WOUND. 

1.  Delayed  healing. 

2.  Blennorrhea. 

3.  Ulceration  and  fungus. 

4.  Circumscribed  omphalitis. 

5.  Gangrene  of  the  stump. 

SEVERE  DISEASES  OF  THE  UMBILICAL  WOUND. 

1.  Umbilical  gangrene. 

2.  Arterial  and  venous  thrombosis. 

3.  Periarteritis  and  periphlebitis. 

Infections  of  the  umbilical  wound,  particularly  of  the  more  severe  forms, 
have  decreased  continually  during  the  last  few  years,  thanks  to  the  great 
progress  in  our  knowledge  of  asepsis.  The  obstetrician  has  learned  to  use 
proper  measures  of  prophylactic  asepsis,  especially  in  the  care  of  the  umbil- 
ical stump.  The  dry  method  of  treatment  has  proved  especially  useful. 
The  stump  of  the  cord  is  wrapped  in  clean  sterile  linen  or  gauze  rather  than 
absorbent  cotton,  which  adheres  too  readily,  and  is  then  held  by  the  usual 
abdominal  binder.  All  antiseptic  fluids  and  ointments  are  avoided  because 
the  moist  warmth  delays  mummification  and  fosters  decay.  The  drying 
process  is  usefully  hastened  by  means  of  such  dusting  powder  as  bolus 
alba,1  or  bismuth  subgallate  in  small  quantity.  As  soon  as  the  dressing 
becomes  moist  or  soiled  it  should  be  changed,  great  care  being  taken  to 
avoid  tearing  the  cord. 

This  same  dry  method  of  treatment  is  applicable  to  the  umbilical  wound 
after  the  cord  separates.  Especially  is  it  necessary,  if  sloughing  occurs  early 
and  there  is  much  exudation  from  the  wound,  to  avoid  anything  that  will 
obstruct  free  drainage. 

.In  private  practice  the  daily  bath  presents  no  dangers  but  in  crowded 
institutions,  where  the  possibility  of  local  infection  exists,  it  is  safer  not  to 
bathe  the  child  until  the  wound  is  healed. 

GANGRENE  OF  THE  STUMP 

Gangrene  of  the  stump,  or  sphacelus,  recognized  by  the  strong  odor  of 
decay,  the  discolored  appearance  and  the  moisture  of  the  gtump  of  the  cord, 
and  causing  resorption  fever,  develops  only  when  the  cord  is  not  properly 
cared  for  and  when  dressing  materials  are  used  which  prevent  drying. 

Treatment  consists  in  the  removal  of  the  decayed  tissue  by  means 
of  the  actual  cautery.  If  this  is  done  soon  enough  rapid  healing  results;  if 

1  Because  of  the  danger  of  the  presence  of  tetanus  bacilli  in  the  bolus  alba  it  must  be 
sterilized  before  use.  Stearate  of  zinc  is  very  successfully  used  as  a  drying  powder. 


DISEASES  OF  THE  NEW-BORN  137 

not,  the  possibility  of  septic  infection  or  of  toxemia  from  the  gangrenous 
area  threatens. 

BLENNORRHEA 

Excoriation  of  the  Umbilicus. — Blennorrhea  is  that  condition  in  which 
a  seropurulent  or  purulent  secretion  occurs  from  the  umbilical  wound  after 
the  stump  has  been  sloughed,  the  depression  in  the  skin  being  slightly 
reddened  and  indolent  granulations  at  the  base  of  the  wound  being  covered 
with  a  mucopurulent  exudate.  The  flow  of  the  secretion  is  obstructed  by 
the  anatomic  relations,  the  retraction  of  the  wound  beneath  the  level  and 
within  the  overlapping  folds  of  the  skin.  In  consequence  and  often  by  aid 
of  constricting  bandages,  the  inflammation  frequently  spreads  to  the 
neighboring  periarterial  tissue  and  to  the  newly  formed  thrombi  in  the 
arteries,  which  become  involved  in  a  purulent  decomposition  for  some 
distance.  In  this  way,  something  resembling  a  fistula  is  formed  into  which  a 
probe  may  be  introduced  for  several  inches  and  from  which  large  quantities 
of  pus  may  be  expressed. 

The  diagnosis  depends  upon  the  continuous  flow  of  the  secretion  from 
the  wound.  It  must  be  remembered  that  the  mere  formation  of  pus  in  the 
navel,  even  though  it  be  extremely  abundant,  is  insufficient  basis  for  a 
diagnosis  of  general  umbilical  sepsis.  It  is  necessary,  therefore,  when  pus 
formation  in  the  navel  is  associated  with  serious  disturbance  of  the  general 
health  to  look  for  other  causes  of  the  major  illness. 

The  prognosis  is  favorable.  The  infection  zarely  spreads  to  the  hypo- 
gastric  arteries  because  of  the  complete  destruction  of  the  thrombi. 

By  way  of  treatment  it  is  of  first  importance  to  provide  free  drainage. 
It  must  be  remembered  that  strips  of  gauze  and  the  free  use  of  anti- 
septic powders  rather  favor  the  continuance  of  the  infective  process  than 
promote  free  drainage  and  granulation.  Sometimes  the  pus  may  be  care- 
fully expressed  from  the  fistula  several  times  daily.  Occasionally,  it  may  be 
necessary  to  open  the  fistula  by  means  of  incision  made  over  a  grooved 
director  to  insure  proper  drainage.  If  this  is  done  and  if  the  child  is  pro- 
tected from  disturbances  of  nutrition,  the  blennorrhea  heals  rapidly. 
Slight  dusting  with  antiseptic  powders  may  aid  in  the  formation  of  granu- 
lations. The  development  of  pyodermia  around  the  umbilicus  may  be 
prevented  by  the  use  of  ointments. 

UMBILICAL  ULCER 

Umbilical  ulcer  may  occur  primarily  or  in  connection  with  blennorrhea. 
In  this  condition  there  is  loss  of  tissue,  varying  from  one-half  to  one  and  one- 
half  inches  in  diameter  of  circular  or  irregular  area  surrounded  by  a  sharply 
defined  infiltrated  edge,  the  base  of  the  lesion  being  covered  with  pus  or  a 
thick  white  exudate.  In  some  cases,  it  resembles  the  primary  lesion  of 
syphilis.  There  are  no  general  symptoms,  excepting  fever.  The  prognosis 
is  favorable,  although  local  or  general  infection  of  the  wound  may 
arise  (Fig.  27). 


138 


TEXT-BOOK  OF  PEDIATRICS 


FIG.  27. — Small  umbilical  ulcer. 


FIG    28. — Granuloma  (Fungus)  of  the  umbilicus. 


DISEASES  OF  THE  NEW-BORN  139 

The  treatment  consists  in  cleanliness,  with  the  application  of  moist  or 
dry  heat,  the  surrounding  skin  being  protected  with  petrolatum.  Peroxide 
of  hydrogen  and  antiseptic  powders  and,  in  some  cases,  the  salts  of  mercury 
used  in  ointment  or  powder  form  give  excellent  results.  Rapid  healing  is 
often  had  upon  the  application  of  a  little  calomel. 

Diphtheria  of  the  umbilicus  appears  as  a  flat  ulceration  covered  by  a 
heavy  membrane,  around  which  there  is  a  hard  and  often  a  widespread 
inflammatory  deposit.  The  diagnosis  should  always  be  confirmed  by 
bacteriologic  examination.  The  prognosis  in  cases  treated  early  is  not  bad. 
Later  cases,  unrecognized,  may  die  of  cardiac  complications.  Antitoxin, 
in  combination  with  local  applications,  is  indicated. 

UMBILICAL  FUNGUS  (GRANULOMA  OF  THE  UMBILICUS) 

If  healing  is  long  delayed,  the  excessive  secretion  and  pus  formation 
may  produce  a  granulomatous  tumor,  the  granuloma  or  fungus  of  the 
umbilicus.  This  growth  appears  as  a  small  red  tumor  the  size  of  a  pea  or  a 
hazel-nut,  arising  from  the  base  of  the  umbilicus.  At  times  the  growth  is 
hidden,  so  that  it  can  be  seen  only  when  the  apposed  surfaces  are  forcibly 
separated  (Fig.  28). 

Besides  the  granulomata,  enteroteratomata  and  adenomata  rarely 
occur.  These  arise  from  inverted  rests  of  the  omphalomesenteric  duct 
which  have  been  separated  by  a  process  of  constriction  from  their  point  of 
origin.  They  are  to  be  distinguished  from  fungus  by  their  smooth  surface, 
the  latter  being  rough  or  papilliform.  In  diagnosis  it  must  be  remembered 
that  a  protruding  fistula  of  the  urachus  or  a  prolapse  of  the  persisting 
omphalomesenteric  duct  may  simulate  a  tumor.  (See  page  135.)  A  mistake 
of  the  one  for  the  other  may  have  serious  results,  since  the  treatment  indi- 
cated for  granuloma  may  cause  perforation  of  the  peritoneum  and  the  bowel. 

In  the  treatment  of  smaller  granulomata,  the  application  of  the  silver 
nitrate  pencil  or  of  chloracetic  acid  is  usually  sufficient  to  shrink  the  gran- 
ulation tissue.  Larger  tumors  must  be  ligated  and  cut  off  with  scissors  or 
removed  by  cauterization. 

OMPHALITIS  (ACUTE  INFLAMMATION  OF  THE  UMBILICAL  RING) 

Omphalitis,  an  inflammation  of  the  umbilical  ring  and  the  surrounding 
skin  and  subcutaneous  cellular  tissue  may  occur  secondarily  to  blennorrhea 
and  ulcer,  as  well  as  primarily  in  the  normal  healing  of  the  umbilical 
wound.  In  the  latter  event  it  arises  from  small  fissures  at  the  edge  of  the 
ring.  The  skin  about  the  umbilicus  becomes  reddened  and  infiltrated. 
The  abdominal  walls  are  tense,  while  to  avoid  pain,  which  is  increased  by 
every  movement,  the  diaphragmatic  breathing  is  extremely  shallow  or 
entirely  absent  and  the  more  active  costal  breathing  is  compensatory.  To 
relieve  the  tension  of  the  abdomen,  the  legs  are  flexed.  The  temperature 
rises  and  with  the  development  of  symptoms  of  more  intense  inflammation 
the  general  health  of  the  patient  is  affected. 


140  TEXT-BOOK  OF  PEDIATRICS 

The  prognosis  is  favorable  if  the  affected  area  is  small.  In  cases  of 
extensive  infiltration  it  must  be  carefully  made,  for  there  is  danger  that  the 
inflammation  may  spread  into  the  deeper  parts  and  that  a  complicating 
peritonitis  may  ensue. 

The  treatment  consists  in  the  application  of  moist  or  dry  heat.  If  an 
abscess  forms,  it  must  be  incised  at  the  proper  time.  In  obstinate  and  wide- 
spreading  infiltration,  it  may  be  necessary  to  open  the  infected  area  freely. 

GANGRENE  OF  THE  UMBILICUS 

Umbilical  gangrene,  so  frequent  in  bygone  days  is  now,  happily,  hardly 
ever  seen.  It  is  usually  secondary  to  some  one  of  the  above  mentioned  con- 
ditions. It  may  be  primary  in  cachectic  infants.  Discolored,  vile-smelling 
tissue  necroses  spread  over  large  areas  of  the  abdominal  skin.  In  especially 
severe  cases,  the  inflammatory  process  extends  to  the  deeper  tissues,  causing 
peritonitis  and  even  intestinal  perforation.  With  fever,  collapse,  and 
extremely  severe  general  symptoms,  this  disease,  the  prognosis  of  which  is 
difficult,  goes  on  to  death.  But  few  cases  are  recorded  in  which  healing  by 
granulation  has  occurred  after  sloughing  of  the  phlegmonous  areas. 

Treatment  is  very  unsatisfactory.  Beyond  the  local  treatment  advised 
for  gangrene,  attention  must  be  given  to  the  conditions  of  feeding  and  nutri- 
tion in  order  that  the  patient's  resistance  may  be  raised. 

MIGRATORY  INFECTION 

A  general  tendency  to  spread  and  to  lead  to  septic  and  pyemic  infections 
is  characteristic  of  this  class  of  umbilical  diseases.  The  general  infection 
may  be  brought  about  by  a  purulent  necrosis  of  the  vessel  thrombi  or 
through  the  lymph  channels  as  an  extending  lymphadenitis. 

A  migratory  infection  of  the  umbilical  arteries  is  the  more  common  form. 
In  this  condition,  we  have  to  deal  chiefly  with  a  periarteritis,  recognized  at 
autopsy  as  a  seropurulent  infiltration  of  the  perivascular  connective  tissue. 
This  directly  causes  an  inflammation  in  the  preperitoneal  space  and  later  of 
the  peritoneum,  with  a  consequent  general  peritonitis  (Fig.  29).  In  rare 
cases,  the  process  descends  in  the  preperitoneal  space  and  breaks  externally 
through  the  inguinal  ring,  causing  funiculitis,  orchitis  and  phlegmon  of  the 
inguinal  region,  the  so-called  preperitoneal  phlegmon.  Thrombo-arteritis 
is  more  rare.  It  differs  from  periarteritis,  which  more  often  follows  the 
normal  healing  of  the  umbilical  wound,  in  that  it  arises  from  pus  formation 
at  the  terminus  of  the  umbilical  arteries  and  frequently  accompanies 
blennorrhea.  It  i?  probable  that,  favored  by  improper  treatment  which 
tends  to  keep  the  wound  open,  the  purulent  necrosis  of  the  thrombus 
spreads,  until  it  finally  reaches  the  hypogastric  arteries  and  thence  causes  a 
general  pyemia.  Arterial  thrombosis  and  periarteritis  may  occur  together. 

In  disease  of  the  umbilical  vein,  lymphangitis  alone  is  hardly  ever 
observed,  because  of  the  slight  development  of  the  perivascular  tissue.  In 
this  vessel,  thrombophlebitis,  or  a  combination  of  thrombo-  and  peri- 


DISEASES  OF  THE  NEW-BORN 


141 


phlebitis  is  more  frequent.  The  disease  of  the  vein  leads  to  peritonitis  or 
hepatitis  or  both,  resulting  frequently  in  multiple  abscesses. 

Of  the  symptoms  of  this  disease,  fever,  only,  is  first  observed;  the  cause 
of  which  is  the  more  obscure  because  the  umbilical  wound,  hi  even  cases  of 
venous  infection,  is  usually  completely  healed.  But  as  soon  as  the  peri- 
tonitis or  pyemia  develops,  the  picture  is  one  of  severe  general  septic 


Fig.  29. — Arteritis  and  periarteritis  of  the  umbilical,  vessels.  Mucopurulent  infiltration 
of  the  arterial  walls  and  the  periarterial  connective 'tissue  extending  to  the  urinary  bladder. 
Beginning  peritonitis. 

infection,  often  showing  pyemic  metastases.  Icterus,  as  is  well  known,  is 
common  in  venous  disease.  This  complication,  if  the  disease  spreads 
slowly,  may  occasionally  occur  during  the  second,  third  or  even  the  fourth 
month.  Abscesses  of  the  liver  may  also  be  postponed  to  so  late  a  period. 

The  prognosis  is  bad  in  almost  all  cases.  Exceptionally  the  purulent 
process  may  be  arrested  and  encapsulation  may  ensue  before  the  appear- 
ance of  general  infection. 

The  treatment  is  that  generally  indicated  in  septic  infection. 


142  TEXT-BOOK  OF  PEDIATRICS 

TETANUS  NEONATORUM 

Etiology. — Tetanus  in  the  new-born  is  distinguished  from  that  in  the 
adult  only  by  the  peculiarity  of  its  port  of  entry.  Almost  invaiiably  the 
umbilical  wound  is  responsible  for  the  invasion  of  the  micro-organism.  The 
soiled  hands  of  those  who  care  for  the  child  and  especially  hands  soiled  with 
garden  earth  or  floor  dust,  the  normal  medium  for  the  tetanus  bacillus, 
carry  the  .infection.  Occasionally  the  materials  for  the  dressings  (bolus 
alba)  may  come  under  suspicion  as  carriers  of  the  infection. 

The  demonstration  of  the  bacillus  is  possible.  For  this  purpose,  the  um- 
bilical wound  is  scraped  with  a  sharp  curette  and  the  material  so  obtained 
is-  injected  into  a  mouse.  The  organism  doefe  not  cause  local  inflamma- 
tory changes  in  the  wound.  If  inflammation  does  occur,  we  have  to  deal 
with  a  mixed  infection  (pyogenic  organisms). 

The  pathologic  findings  are  those  of  congestion  in  the  central  nervous 
system.  Occasionally,  extensive  hemorrhages  are  present. 

The  incubation  period  is  sometimes  very  short,  symptoms  appearing 


FIG.  30. — Tetanus  neonatorum.    Typical  facial  expression. 

as  early  as  the  first  or  second  day.    Most  cases  appear  by  the  end  of  the  first 
week;  but  a  few  in  the  second  and  third  week. 

Symptoms. — The  earliest  symptom  is  trismus,  first  recognized  by  the 
difficulty  in  introducing  the  nipple.  The  rigidity  soon  spreads  to  the  face 
and  graduaUy  appeals  in  the  muscles  of  the  trunk  and  of  the  arms  and  legs, 
so  that  the  whole  body  eventually  becomes  stiff.  The  child's  face  is 
characteristic;  the  tetanic  facies,  with  wrinkled  forehead,  closed  eyelids, 
taut  cheeks,  hardened  by  the  contraction  of  the  masseters,  slightly  puckered 
and  firmly  compressed  lips,  with  the  angles  of  the  mouth  drawn  down  pro- 
ducing the  risus  sardonicus  (Fig.  30) ,  completing  the  picture.  In  the  further 
course  of  the  disease,  lightning-like  tetanic  spasms  passing  over  the  whole 
body  like  a  flash,  occur.  In  the  interval,  the  patient  lies  silent,  perfectly 
rigid,  frequently  in  opisthotonos,  with  distended  legs  and  rigidly  flexed 
arms.  With  the  extension  of  the  tetanus  to  the  respiratory  muscles,  disturb- 
ances of  respiration  and  cyanosis  appear.  The  more  severe  the  type,  the 
more  frequent  the  spasms.  In  extreme  cases  rises  in  temperature  are 
observed,  which  occasionally  show  most  peculiar  variations  and  may  reach 
a  stage  of  hyperpyrexia. 


DISEASES  OF  THE  NEW-BORN  143 

Diagnosis. — The  diagnosis  may  always  be  made  from  the  clinical  pic- 
ture. The  demonstration  of  the  bacillus  is  not  necessary,  since  a  negative 
result  is  of  no  value.  Of  course,  the  differentiation  from  similar  diseases  is 
not  always  easy.  Tonic  contractions  in  the  new-born  are  also  seen  in  such 
birth  injuries  as  cerebral  and  meningeal  hemorrhages,  in  encephalitis  and 
other  cerebral  processes.  In  the  latter,  the  involvement  of  the  ocular  mus- 
culature is  a  valuable  point  of  differentiation;  it  is  absent  in  tetanus. 

Prognosis. — In  general,  the  prognosis  is  very  unfavorable;  from  seventy 
to  eighty  per  cent,  of  cases  die.  In  individual  instances,  the  prognosis  will 
depend  upon  the  length  of  the  incubation  period  and  the  severity  of  the 
infection.  Long  periods  of  incubation,  relatively  infrequent  spasms,  ab- 
sence of  respiratory  impairment  and  cyanosis  and  of  excessive  temperature 
permit  a  more  favorable  although  guarded  outlook. 

Treatment. — The  treatment  consists  chiefly  in  measures  for  the  relief 
of  the  convulsions.  Absolute  quiet  and  removal  from  all  possibility  of  ex- 
ternal shock  is  to  be  advised.  Light  moist  or  dry  packs  reduce  the  irritating 
influence  of  air  currents  and  of  temperature  changes. 

Chloral  hydrate  0.5  gm.  (7  grs.),  at  a  dose,  up  to  3.0  gms.  (45  grs.) 
per  day  has  been  used,  in  most  cases  in  combination  with  the  bromides, 
preferably  calcium  bromide,  1-2.0  gms.  (15-30  grs.)  per  day  in  aqueous 
solution,  or  veronal,  0.075  gm.  (1  gr.)  per  dose.  These  are  best  given 
by  rectum.  The  antispasmic  action  of  an  injection  of  a  salt  of  magnesium 
(20  c.c.  of  an  8  per  cent,  solution  of  magnesium  sulphate),  may  be  tried. 

Great  difficulty  is  encountered  in  feeding  on  account  of  the  trismus. 
Expressed  breast-milk  or  artificial  food  is  to  be  given  from  a  spoon,  and,  if 
necessary,  through  the  nose.  In  severe  cases,  it  is  preferable  to  avoid 
repetitional  excitement  and  to  feed  only  three  times  a  day  through  a 
catheter.  The  required  quantity  of  water  may  be  given  in  small  enemata 
or  by  enteroclysis  (see  page  111). 

Serum  therapy  cannot,  as  yet,  show  absolute  results.  One-half  of  a  tube 
of  antitetanic  serum,  containing  250  units,  should  be  injected  subcutane- 
ously  around  the  umbilicus  and  the  other  half  into  the  spinal  canal  by 
lumbar  puncture. 

Since  the  above  was  written  the  value  of  antitetanic  serum  has  been 
definitely  proved.  The  physician  is  justified  in  giving  it  even  before  the 
bacteriologic  diagnosis  is  established.  Much  larger  quantities  up  to  1000  to 
2000  units,  may  be  given  and  repeated. 

UMBILICAL  HEMORRHAGE 

Umbilical  hemorrhage  may  come  from  the  arteries,  either  before  or  after 
the  separation  of  the  cord,  or  it  may  come  from  the  parenchyma  (idiopathic 
hemorrhage).  Hemorrhage  from  the  vessels  indicates  a  failure  of  their 
physiologic  closure,  while  an  idiopathic  hemorrhage  shows  a  local  or  general 
decrease  of  the  physiologic  coagulability  of  the  blood  or  an  abnormal  per- 
meability of  the  vessel  walls. 


144  TEXT-BOOK  OF  PEDIATRICS 

Hemorrhage  from  the  vessels  while  the  cord  is  still  attached  should  never 
be  laid  to  unsuccessful  ligation  of  the  cord,  since  the  physiologic  sequel®  of 
birth,  in  the  way  of  constriction  of  the  vessels  and  reduction  of  blood-pres- 
sure through  the  expansion  of  the  lungs  suffice,  under  normal  conditions,  to 
stop  the  bleeding  even  without  ligation.  Hence,  it  is  always  well  to  search 
for  more  remote  causes  of  umbilical  hemorrhage  (pulmonary  atelectasis, 
asphyxia,  heart  lesions,  etc.). 

In  the  rare  cases  of  hemorrhage  which  occur  after  separation  of  the  cord, 
the  formation  of  thrombus  and  the  closure  of  the  vessels  by  the  organization 
of  the  clot  are  delayed  by  causes  as  yet  unknown;  possibly  by  a  reduction  of 
the  coagulability  of  the  blood  incident  to  infection. 

Parenchymatous  bleeding  is  the  result  either  of  general  sepsis,  which 
reduces  the  blood  coagulability  or,  more  rarely,  of  local  infection  which 
prevents  the  formation  of  solid  thrombi. 

In  the  treatment  of  hemorrhage  from  the  vessels  of  the  umbilical  cord  it 
is  necessary  to  tie  off  the  cord  with  special  care  and  for  this  purpose  elastic 
bands  are  to  be  recommended.  The  respiration  should  be  persistently  and 
carefully  watched.  Hemorrhage  after  the  separation  of  the  cord  is  stopped 
by  painting  with  epinephrin  solution  (1 : 1000),  by  touching  with  the  thermo- 
cautery  or  by  taking  sutures  around  the  navel  through  the  abdominal 
walls.  In  parenchymatous  hemorrhage  all  these  measures  are  useless.  In 
this,  as  in  all  other  hemorrhage  uncontrolled  by  such  measures,  the  attempt 
must  be  made  to  overcome  the  bleeding  by  local  applications  and  by  sub- 
cutaneous injection  of  10  to  20  c.c.  (2-4  drams)  of  sterile  gelatin  solution. 
The  injection  of  human  serum,  obtained  as  fresh  as  possible — a  method 
recently  used  with  success,  may  be  considered. 

Experience  has  shown  that  hemorrhage  from  the  umbilicus  is  very  fre- 
quently a  manifestation  of  idiopathic  hemorrhagic  disease  of  the  new-born. 
Coagulation  and  bleeding  time  should  be  tested  in  every  case  and  when 
they  are  found  to  be  prolonged,  subcutaneous  injections  of  whole  blood 
should  be  given  in  the  amount  of  30  c.c.  once  or  twice  daily,  until  the  hemor- 
rhage is  controlled,  and  the  bleeding  and  coagulation  time  becomes  normal. 

SEPSIS 

While  septic  diseases  of  every  grade,  from  the  mildest  to  the  most  severe, 
were  formerly  common  in  institutions  for  children  and  in  lying-in  hospitals 
where  they  are  still  observed,  yet,  they  have  now,  thanks  to  the  advance  of 
hygiene,  become  much  less  frequent. 

In  their  etiology  many  forms  of  micro-organisms  are  concerned.  The 
ordinary  pyogenic  bacteria,  the  staphylococci  and  the  streptococci  and  the 
pneumococci,  are  particularly  observed,  but  other  varieties,  as  the  bacillus 
coli,  Friedlaender  's  bacillus,  the  bacillus  of  hemorrhagic  septicemia,  the 
bacillus  pyocyaneus  and  certain  strains  of  proteus,  are  occasionally  among 
their  causative  factors. 

The  fetus  may  become  infected,  even  in  utero,  by  the  passage  of  germs 
from  the  diseased  placenta.  A  second  possibility  of  infection  before  birth 


DISEASES  OF  THE  NEW-BORN  145 

occurs  between  the  rupture  of  the  membranes  and  the  end  of  delivery. 
Such  occasions  of  disease  transmission  are,  of  course,  rare  as  compared  with 
those  which  develop  postpartum.  After  birth,  the  umbilicus  is  the  chief 
port  of  entry  for  pathogenic  organisms;  but  the  general  surface  of  the  skin  is 
the  subject  of  so  frequent  and  so  numerous  wounds — erosions,  rhagades, 
intertrigo,  etc.,  during  the  early  days  of  life,  that  many  other  opportunities 
of  infection  are  offered.  Usually,  only  local  disturbances,  such  as  furuncles, 
abscesses  and  phlegmons,  occur;  to  which,  later,  general  septic  or  pyemic 
developments  maybe  added.  The  mucous  membrane  may  also  offer  a  route 
of  invasion  for  micro-organisms.  From  injuries  to  the  buccal  surfaces, 
usually  caused  by  the  meddlesome  care  of  the  mouth,  formerly  in  so  common 
vogue,  stomatitis,  and  Bednar's  aphtha  may  be  traced  and  general  septic 
disease  may  take  origin.  More  frequently  however,  the  primary  septic  focus 
is  to  be  found  in  the  pharynx,  in  the  nasal  mucous  membrane,  the  con- 
junctiva, the  tonsils,  the  ear,  or  the  intestine.  The  possibility  of  general 
infection  from  the  lung  and  from  the  urinary  tract  must  also  be  considered. 

The  transmission  of  the  infection  results  from  numerous  forms  of  con- 
tact (fomites,  hands,  utensils,  lochia,  etc.).  The  theory,  occasionally 
advanced,  that  infection  comes  by  way  of  the  mother's  or  cow's  milk, 
containing  germs,  is  not  tenable.  Undoubtedly,  disturbances  of  nutrition 
increase  the  liability  to  infection  to  a  great  degree  by  reducing  the  immun- 
izing forces  of  the  body  and  therefore,  infective  disease  is  more  common  in 
artificially-fed  children. 

The  structural  basis  of  sepsis  varies  widely  with  the  numerous  clinical 
pictures  which  present  themselves.  In  the  more  acute  cases,  the  autopsy 
findings  are  often  very  indefinite  and  are  confined  to  parenchymatous 
degenerative  lesions.  In  cases  of  longer  duration,  more  marked  visceral 
changes  may  be  seen.  Hemorihages  from  the  serosse  are  especially  frequent. 
Evidences  of  pneumonia,  gastro-enteritis,  and  numerous  metastatic,  serous, 
sero-hemorrhagic  or  purulent  foci  of  inflammation  (embolic  abscesses,  septic 
infarcts,  osteomyelitis,  empyema,  synovitis,  etc.),  are  associative. 

With  its  greatly  varied  etiology  and  with  the  large  number  of  entry 
ports  of  septic  infection,  the  disease-picture  is  also  extremely  variable,  as 
regards  alike  the  severity  of  the  general  toxemia  and  the  localized  disease  in 
individual  organs.  However,  the  majority  of  cases  are  similar  in  so  far 
as  the  symptoms  of  general  intoxication  are  concerned  and  these  are  usually 
more  marked  than  is  common  in  older  patients,  Fever,  restlessness,  alter- 
nating with  apathy,  a  tendency  to  collapse,  and  disturbances  of  conscious- 
ness are  usually  present.  Disorders  of  the  digestive  tract  in  the  foim  of 
diarrhoea,  with  rapid  losses  of  weight,  are  almost  always  observed  and  these 
often  appear  in  so  pronounced  a  form  that  the  sepsis  runs  its  course  mis- 
takenly diagnosed  as  a  gastro-intestinal  disease.  The  similarity  of  the 
picture  of  severe  primary  dyspepsia  with  toxic  conditions,  as  it  develops 
frequently  in  the  course  of  a  pure  disturbance  of  nutrition,  will  be  readily 
understood.  In  fact,  the  septic  process  usually  develops  in  such  a  way  that 
the  parenteral  disease  becomes  the  cause  of  severe  alimentary  disturbance. 
10 


146  TEXT-BOOK  OF  PEDIATRICS 

Sometimes,  the  sepsis  develops  within  a  very  brief  period  and  the  diag- 
nosis is  possible  only  by  bacteriologic  examination.  In  other  cases,  the 
process  covers  a  longer  time  and  various  other  symptoms  may  be  observed. 

Symptoms. — Fever  is  usual;  high  and  irregular  rises  of  temperature 
especially  at  the  beginning  of  the  disease  are  often  followed,  earlier  or  later, 
by  a  marked  fall  and  collapse.  At  times,  every  rise  in  temperature  from  the 
very  beginning  is  succeeded  by  collapse.  Chills,  so  common  in  older 
patients,  are  never  seen. 

In  the  urine,  albumin,  casts  and  epithelial  cells  are  always  found  as 
an  expression  of  the  toxic  effect  upon  the  kidneys;  at  times  a  hemor- 
rhagic  nephritis  or  cysto-pyelitis  may  develop.  Enlargement  of  the  spleen 
and  liver  is  common,  but  is  of  diagnostic  value  only  when  it  appears 
during  the  course  of  the  disease.  Numerous  changes  in  the  skin  are  indica- 
tive of  toxemia.  Septic  erythemata,  which  resemble  either  scarlet  fever, 
measles  or  erythema  multiformi,  occur.  Hemorrhages,  in  the  form  of  small 
petechise  or  large  ecchymoses,  are  characteristic  and  of  diagnostic  signifi- 
cance. The  color  of  the  skin  is  at  times  grayish,  as  in  anilin  poisoning. 
Often  the  skin  and  mucous  membranes  become  yellow  because  of  a  com- 
plicating icterus. 

It  is  customary  to  distinguish  a  hemorrhagic,  a  gastro-intestinal  and  a 
pneumonic  form  of  sepsis  according  to  the  prevalence  of  certain  groups  of 
symptoms. 

A  true  pyemia  characterized  by  metastatic  abscesses  is  not  very  common 
in  the  new-born,  nor  at  any  period  of  childhood.  Probably  the  low  degree 
of  resistance  at  this  age  does  not  favor  the  slow  course  of  the  disease  neces- 
sary to  abscess  formation.  Nevertheless,  it  does  occur  now  and  then  and 
runs  a  course  showing  special  tendency  to  metastases  in  the  skin  and  to 
embolic  abscesses  in  the  internal  organs,  to  pyemia  of  the  joints  or  to  osteo- 
myelitis. Endocarditis  and  pericarditis  are  comparatively  rare. 

Buhl's  and  Winckel's  disease  are  to  be  regarded  as  forms  of  sepsis 
having  a  peculiar  course.  Their  etiology  has  not  been  explained.  The  Buhl 
type  produces  a  fatty  degeneration  of  the  heart,  liver  and  kidney  resembling 
that  of  phosphorus  poisoning,  together  with  hemorrhages  in  various  organs 
and  in  the  skin.  The  children  affected  by  these  very  rare  diseases  are  born 
asphyctic  and  severe  manifestations  of  disease  soon  appear,  such  as  diar- 
rhoea, loss  of  weight,  hemorrhage  and  sopor.  Most  cases  die  and  death 
occurs  early  with  extreme  cyanosis  and  icterus. 

The  chief  symptoms  of  Winckel's  disease  are  hemoglobinemia  and 
hemoglobinuria.  The  disease  runs  its  course  with  cyanosis,  icterus,  dysp- 
noea and  gastro-intestinal  manifestations  and  usually  results  in  death  in  a 
very  short  time. 

The  diagnosis  is  based  upon  the  recognition  of  a  port  of  entry,  upon  the 
existence  of  metastatic  foci,  which  may,  however,  be  hard  to  demonstrate, 
and  upon  the  appearance  of  petechiaB,  icterus,  etc.  The  chief  difficulty  lies 
in  its  differentiation  from  alimentary  intoxication,  a  distinction  which  is  all 
the  more  important  because  parenteral  infections  in  the  young  infant  tend 


DISEASES  OF  THE  NEW-BORN  147 

to  cause  secondary  disturbances  of  nutrition.  In  alimentary  cases,  the 
effect  of  dietetic  treatment  upon  the  fever,  the  toxic  symptoms  and  the 
diarrhoea  make  the  primary  cause  clear.  The  bacteriologic  examination  of 
the  blood  cannot  be  undertaken  outside  of  the  hospital,  because  it  is  not 
always  possible  to  obtain  the  required  amount  of  blood,  which  should  be, 
at  least,  2  c.c.  (%  dram). 

The  prognosis  is  always  grave.  The  more  abrupt  the  onset  and  the  more 
rapid  the  course  of  the  septic  process,  the  less  prospect  is  there  of  keeping  the 
patient  alive.  In  the  pyemia  of  gradual  development  and  slow  course  the 
hope  of  successfully  combating  the  disease  is  better  justified.  Occasion- 
ally, cases  in  which  hope  is  apparently  lost  may  recover  if  nutrition  is 
well  sustained. 

Prophylaxis. — The  experience  of  hospitals  and  infant  homes  has  taught 
us  that  much  may  be  accomplished  in  combating  sepsis  by  proper  prophy- 
lactic measures.  It  has  been  shown,  first  of  all,  as  already  noted,  that  the 
sources  of  infection  may  be  reduced  and  the  number  of  entry  ports  for 
infective  organisms  may  be  decreased  by  proper  care  of  the  skin  and  the 
umbilicus,  by  frequent  changing  and  by  the  avoidance  of  meddlesome 
cleansing  of  the  mouth.  In  the  home,  also,  it  is  necessary  to  guard  the 
new-born  infant  with  the  greatest  possible  cleanliness  and  asepsis. 

Special  care  must  be  taken  when  the  mother  has  a  puerperal  infection. 
In  this  event,  it  is  better  that  the  mother  and  the  child  should  be  cared  for 
by  different  persons.  If  this  is  impossible,  the  child's  toilet  should  always 
be  attended  to  before  the  mother 's,  in  order  to  protect  it  from  contamina- 
tion. This  is  advisable  even  when  the  puerperal  mother  is  well,  because 
even  the  normal  lochia  may  contain  pathogenic  organisms.  On  the  other 
hand,  the  danger  that  threatens  the  child  from  the  milk  of  a  puerperally 
diseased  mother  is  much  overrated.  It  has  never  been  demonstrated  that 
septic  infection  is  introduced  in  this  way.  In  cases  where  there  is  any 
anxiety  on  this  score  the  expressed  milk  may  be  fed.  Not  even  the  milk  of  a 
woman  suffering  with  mastitis  seems  to  be  dangerous  to  the  infant,  in  so  far, 
at  least,  as  the  defensive  measures  of  the  intact  mucous  membrane  of  the 
mouth  are  concerned. 

Treatment. — In  the  treatment  of  sepsis,  suitable  feeding  is  the  first 
requirement;  since  it  has  been  shown  beyond  a  doubt  that  the  formation 
of  immune  bodies  is  favored  in  the  greatest  degree  by  proper  diet,  while 
Improper  feeding  definitely  lessens  immunity.  It  is  often  possible  to 
maintain  the  bodily  strength  of  the  child  at  so  high  a  stage  with  mother's 
milk  that  the  infection  may  be  overcome.  In  fact,  those  methods  of  feeding 
which  determine  the  general  well-being  of  the  infant  in  health  are  similarly 
beneficial  in  sepsis,  so  that  the  mother's  milk  is  the  main  reliance.  Particu- 
larly in  those  cases  in  which  intestinal  disturbance  become  prominent 
much  may  be  expected  from  proper  feeding.  They  should  be  treated  by  the 
identical  methods  that  obtain  in  similar  conditions  arising  from  alimentary 
causes.  (Compare  Disturbances  of  Nutrition.)  Local  pus  formation  must 
be  treated  according  to  surgical  requirements.  Strong  antiseptics,  espe- 
cially phenol  and  iodoform,  are  to  be  avoided. 


148  TEXT-BOOK  OF  PEDIATRICS 

For  the  rest,  it  may  be  necessary  to  stimulate  the  heart  by  the  use  of 
camphorated  oil  (7  minims,  subcutaneously,  several  times  a  day2) ;  or  with 
citrated  caffein  or  caffein  sodio-salicylate  4  c.c.  (1  dram)  of  a  0.5  to  1  per 
cent,  solution,  four  or  five  times  a  day,  or  with  a  solution  of  epinephrin 
(1 : 1000),  7-15  minims.  In  high  fever,  tepid  baths  are  useful.  If  there  is  a 
tendency  to  collapse,  hot  baths,  carefully  applied  may  be  employed.  Neither 
collargol,  by  enema  or  in  form  of  an  ointment,  nor  antistrepticoccic  serum 
have  given  any  definite  results. 

HELENA  NEONATORUM 

The  passage  of  large  quantities  of  pure  blood  from  the  gastro-intestinal 
tract  has  customarily  been  called  melena.  The  blood  is  voided  either  by 
vomiting  or  by  stool.  A  form  of  pseudo-melena  (melena  spurid),  occurs,  in 
which  the  vomited  blood  is  of  different  origin.  It  may  arise  from  an  epis- 
taxis  or  be  derived  from  a  wound  in  the  nipple  of  the  nurse.  In  true  melena 
the  gastro-intestinal  tract  of  the  patient  is  the  direct  source  of  the  hemorrhage. 

Under  this  proper  designation,  however,  a  symptomatic  melena  and  a 
true  melena  may  be  distinguished.  Symptomatic  melena  is  a  result  or 
manifestation  of  some  other  disease.  It  sometimes  occurs  in  diseases  of  the 
liver  (lues),  or  in  other  processes  causing  severe  congestion.  The  most 
common  causes,  however,  are  septic  and  septo-hemorrhagic  infections,  in 
which  the  melena  occurs  only  as  one  form  of  other  and  multiple  hemor- 
rhages. In  many  cases,  such  infection  is  introduced  by  specific  hemorrhage 
producing  organisms. 

The  origin  of  true  melena  (melena  verd)  is  still  wholly  obscure.  Nothing 
more  is  known  than  that  the  blood  usually  comes  from  small  ulcers  in  the 
stomach  or  duodenum  and,  more  rarely,  in  other  parts  of  the  tract.  But  it 
may  be  possible  that  even  these  are  absent  and  that  in  autopsy  only  hemor- 
rhage from  the  mucous  membranes  or  a  simple  hyperemia  is  found.  Nothing 
definite  can  be  said  about  the  mode  of  origin  of  these  ulcers.  The  once 
accepted  theory  that  they  are  caused  by  embolisms  from  thrombi  of  the 
umbilical  veins,  does  not  seem  plausible.  At  present,  thrombosis  of  small 
intestinal  vessels  with  consequent  hemorrhage  and  resulting  tissue  digestion 
is  considered  more  probable.  This  thrombosis  may  be  caused  by  a  vaso- 
motor-ischemia.  The  significance  of  concurrent  disturbances  of  nutrition 
may  be  understood  from  the  frequent  occurrence  of  duodenal  ulcers  in 
severe  atrophic  conditions  (decomposition).  The  theory  is  also  advanced 
that  conditions  of  central  nervous  irritation  may  cause  hemorrhages  from 
the  intestinal  mucosa  and  that  the  hemorrhagic  areas  are  then  converted 
into  ulcers  by  action  of  the  digestive  fluids. 

The  hemorrhages  usually  begin  by  the  second  to  the  fourth  day,  although 
occasionally  they  appear  earlier  or  later.  Unimportant,  at  first,  they  soon 
reach  the  stage  in  which  tarry  stools  are  passed,  or  clotted  masses  of  blood 

2  Recently,  objections  have  been  raised  against  the  use  of  camphor  in  severe  general 
infections. 


DISEASES  OF  THE  NEW-BORN  '    149 

vomited.  The  weakness  and  anemia  resulting  depend  upon  the  severity 
and  duration  of  the  hemorrhage.  Some  children  bleed  to  death  rapidly; 
in  others,  the  condition  extends  even  to  the  second  week.  Of  the  untreated 
cases,  more  than  one-half  die. 

The  diagnosis  must  determine  whether  it  is  a  false  or  symptomatic 
melena,  or  a  true  melena.  This  is  all  important  to  the  prognosis.  The 
symptomatic  form  and  especially  the  hemorrhages  dependent  upon  sepsis 
have  a  very  unfavorable  prognosis.  A  prolonged  bleeding  and  coagulation 
tune  are  practically  always  present  in  true  melena. 

Treatment. — By  way  of  treatment  subcutaneous  injections  of  gelatin 
may  be  given  and  repeated  if  necessary.  The  gelatin  may  be  obtained  free 
from  tetanus  and  completely  sterile  in  ampules,  10-25  c.c.  (2-6  drams). 
Many  cases  have  been  saved  by  this  method.  The  subcutaneous  injection 
of  10  to  20  c.c.  (23^-5  drams)  of  serum,  preferably  human,  has  been  recom- 
mended. The  horse  serum  may  be  substituted  if  the  human  cannot  be 
obtained.  In  urgent  cases,  whole  blood  may  be  used  instead  of  serum. 
Recent  experiences  show  that  30  c.c.  of  blood  taken  from  the  mother  by 
means  of  the  ordinary  Luer  syringe  and  injected  subcutaneously  is  very 
efficient .  The  syringe  may  be  lined  with  sterile  petrolatum  or  the  blood 
may  be  citrated  (sodium  citrate  2  per  cent.)  but  these  precautions  are  not 
essential.  The  injection  may  be  repeated  daily,  or  more  often  if  necessary. 
All  other  measures  (ice,  liquor  ferri  sesqui-chlorate,  epinephrin,  etc.),  are 
uncertain.  Upon  occasion,  the  usual  treatment  for  collapse  and,  in  certain 
cases,  the  transfusion  of  salt  solution,  must  be  considered. 

ERYSIPELAS 

Erysipelas  of  the  new-born  does  not  differ  etiologically  from  the  disease 
at  any  later  age,  but  is  distinguished  from  it  by  its  increased  tendency  to 
spread  and  its  resulting  malignancy.  It  usually  arises  from  either  the  um- 
bilicus or  the  genital  organs  and  begins  at  the  end  of  the  first  or  second  week. 

It  begins  with  redness  and  edematous  swelling  of  the  affected  part, 
which  increases  in  diameter  and  spreads  rapidly.  High  fever  develops  and 
in  many  cases  alternates  with  collapse  temperatures.  The  general  health 
of  the  child  is  severely  affected.  At  times,  skin  necroses,  phlegmonous,  gan- 
grenous and  general  septic  processes  develop  from  the  erysipelas  as  a  base. 

In  the  diagnosis,  the  differentiation  from  phlegmon  must  be  especially 
considered.  The  prognosis  is  very  unfavorable  in  the  new-born;  certainty 
much  more  unfavorable  than  it  is  in  somewhat  older  infants,  to  say  nothing 
of  children  of  more  advanced  years. 

The  treatment  is  that  generally  used  in  this  disease ;  (ichthyol  ointment, 
alcohol,  mercuric  bichloride,  1:1000,  aluminum  acetate,  etc.,  externally). 
Applications  of  saturated  solution  of  magnesium  sulphate  are  of  great  value. 
Special  attention  must  be  given  to  the  maintenance  of  the  general  quality 
of  resistance  by  the  feeding  of  mother's  milk  and  of  the  strength  of  the 
heart,  in  particular,  by  means  of  stimulants. 


150  TEXT-BOOK  OF  PEDIATRICS 

OPHTHALMIA  NEONATORUM 

Severe  purulent  catarrh  of  the  conjunctiva  is  frequent  in  the  new-born; 
partly  because  of  a  special  predisposition  upon  the  part  of  the  mucous 
membranes  of  early  life,  and  partly  because  the  passage  of  the  child  through 
the  infected  birth  canal  affords  especially  favorable  opportunities  for  con- 
junctival  infection.  In  fact,  the  majority  of  children  are  infected  with  the 
disease  during  labor  if  the  mother  is  suffering  from  any  form  of  purulent 
vaginitis.  The  number  who  acquire  the  disease  later,  by  some  other  form 
of  contact,  is  small. 

Etiology. — The  gonococcus  is  usually  considered  the  most  common 
agent  in  the  production  of  blennorrhea.  The  so-called  inclusion  or  chlamy- 
dozoa  blennorrhea  is  almost  equally  frequent,  however,  with  the  gonococci 
form.  Clinically  it  has  a  great  resemblance  to  the  latter,  but  in  general 
pursues  a  milder  course.  By  staining  smears  according  to  the  Giemsa 
method,  the  inclusions  of  epithelium  as  described  by  Halberstaedter  and 
Prowazek,  may  be  demonstrated  in  large  numbers,  while  gonococci  are 
absent.  Pneumococcic  conjunctivitis,  the  catarrhal  infection  produced  by 
the  Koch- Weeks  bacillus  and  other  forms  are  known. 

Symptoms  of  the  gonorrheal  form,  which  is  the  most  severe,  appear  by 
the  second  or  third  day  in  the  form  of  a  reddening  and  edema  of  the  lids, 
while  a  thinsero-hemorrhagic  secretion  appears  between  them.  The  eyes  can 
be  opened  with  difficulty,  the  lids  are  tense  and  the  conjunctiva  chemotic. 

In  severe  cases,  the  lids  may  become  so  tense  that  danger  of  gangrene 
arises,  and  the  conjunctiva  shows  a  membranous  exudate.  After  several 
days,  the  swelling  goes  down  and  large  quantities  of  pus  are  secreted  while 
the  connective  tissue  appears  slightly  granular. 

The  duration  of  uncomplicated  cases  is  usually  from  six  to  eight  weeks, 
when  recovery  sets  in.  The  danger  of  keratitis  with  perforation  always 
threatens.  It  is  a  generally  accepted  fact  that  about  one-third  of  all  blind- 
ness is  due  to  blennorrhea.  Gonorrheal  arthritis,  synovitis,  dermal  ab- 
scesses and  exanthemata  are  among  the  complications  of  the  local  infection. 

The  course  of  blennorrhea  due  to  micro-organisms  other  than  the  gono- 
coccus is  usually  shorter  and  its  result  more  favorable;  but  damage  to  the  • 
cornea  is  not  always  avoided. 

The  value  of  Crede's  prophylactic  method  of  instilling  one  drop  of  a 
1  per  cent,  silver  nitrate  solution,  or  some  less  irritating  silver  salt,  in  each 
eye  is  recognized.  The  catarrhal  conjunctivitis  which  the  silver  may  cause 
may  be  disregarded  in  view  of  the  great  benefits  of  the  method. 

Treatment. — The  treatment,  during  the  stage  of  swelling,  consists  of 
measures  to  reduce  the  inflammation.  Applications  of  ice  are  frequently 
recommended,  but  the  extreme  cold  may  be  injurious  at  this  stage.  No 
damage  will  be  done  by  dry  or  moist  heat.  In  addition,  irrigation  with 
warm  antiseptic  solutions  (boric  acid  solution,  mercuric  bichloride, 
1 : 5000),  may  be  useful.  After  pus  formation  is  fully  established,  the  physi- 
cian himself  should  touch  the  averted  lids  daily  with  a  1  to  2  per  cent,  solu- 
tion of  silver  nitrate,  after  which  the  eyes  should  be  carefully  washed  out 


DISEASES  OF  THE  NEW-BORN  151 

with  physiologic  salt  solution.  Several  drops  of  a  two  per  cent,  solution  of 
protargol  or  argyrol  (freshly  prepared  without  heating)  may  be  instilled  into 
the  eye  in  place  of  the  silver  nitrate.  In  all  methods  of  treatment,  injury  to 
the  cornea  must  be  very  carefully  guarded.  If  only  one  eye  is  affected,  the 
sound  eye  should  be  washed  daily  with  a  half  of  one  per  cent,  solution  of  sil- 
ver nitrate  and  may  be  covered  with  a  protection  bandage.  Involvement  of 
the  cornea  should  be  treated  occording  to  ophthalmologic  methods.  The 
articular  metastases  will  heal,  without  opening  the  joint,  with  applications 
of  heat  or  of  Bier's  hyperemia,  or,  at  most,  by  puncture.  In  obstinate 
cases,  vaccine  treatment  may  be  tried. 

SWELLING  OF  THE  MAMMARY  GLAND  AND  MASTITIS 

In  quite  a  number  of  new-born  infants  of  both  sexes,  swelling  of  the 
mammary  gland  begins  two  or  three  days  after  birth.  It  increases  until  the 
middle  of  the  second  week  and  then  gradually  disappears.  During  this  pe- 
riod, the  so-called  "  witch  's-milk, "  which  very  closely  resembles  colostrum, 
may  be  expressed  from  the  gland,  so  that  we  have  to  deal  with  an  actual  se- 
cretory function  similar  to  that  of  the  maternal  breast.  The  probable  cause 
of  this  phenomenon  is  to  be  found  in  the  lactogen,  a  substance  which,  accord- 
ing to  the  latest  researches,  is  produced  by  the  ovaries  and  the  uterus  and 
which  in  gravid  puerperal  women  stimulates  the  production  of  milk.  This 
agent  passes  by  way  of  the  placenta  into  the  circulation  of  the  child  and 
acts  specifically  upon  the  infant  breast.  Upon  the  invitation  of  this  physio- 
logic activity,  infection  may  occur  and  mastitis  may  develop,  especially  if, 
in  line  with  an  old  and  objectlonal  popular  practice,  the  fluid  is  expressed. 
The  turgescence  further  increases,  fever,  redness  and  abscess  formation  or 
phlegmon  ensue;  from  which  source,  occasionally,  a  general  infection  may 
arise.  The  prognosis  of  mastitis,  however,  is  generally  good. 

The  treatment  consists  primarily  in  measures  to  reduce  the  inflam- 
mation, followed  later,  if  necessary,  by  incision.  Radial  incision  should  be 
carefully  done  to  avoid  severing  the  ducts. 

ICTERUS  NEONATORUM 

Jaundice  occurs  in  more  than  eighty  per  cent,  of  all  new-born  infants, 
from  the  second  to  the  fifth  day.  It  appears  first  in  the  face  and  then  de- 
scends over  the  body.  The  sclera  are  affected  much  later.  Other  manifesta- 
tions of  disease  are  absent.  The  feces  are  colored  with  bile.  The  urine  is  light 
in  color  and  is  negative  to  the  usual  tests  for  bile  pigment.  Microscopically, 
however,  brownish-yellow  masses  of  bilirubin,  either  free  or  in  epithelial  or 
hyaline  casts  ("masses  jaunes"),  are  found  (Fig.  31).  The  jaundice  lasts 
from  a  few  days  to  three  weeks;  in  exceptional  cases  only,  and  especially  in 
premature  infants,  is  it  present  for  a  longer  time.  The  whole  phenomenon 
is  quite  unimportant  and  is  considered  a  physiologic  one. 

No  anatomic  lesion  is  found  in  infants  with  jaundice  who  die  from  other 
causes.  Bilirubin  crystals  may  be  demonstrated  in  the  tissues. 


152 


TEXT-BOOK  OF  PEDIATRICS 


Of  the  cause  of  icterus  neonatorum,  nothing  definite  is  yet  known.  The 
older  theories  which  attempted  to  show  that  it  was  of  hematogenous  origin 
and  caused  directly  by  the  resorption  of  the  products  of  a  catabolism  of  the 
hemoglobin  derived  from  extravasated  or  broken-down  red  blood-cells, 
independently  of  any  action  of  the  liver,  have  been  disproved  by  the  demon- 
stration of  bile  acids  in  the  urine  and  in  the  tissues,  the  presence  of  which 
can  be  due  alone  to  a  resorption  of  bile.  Quincke  's  theory  to  the  effect  that 
the  bile  massed  in  the  meconium  passes  directly  into  the  blood  through  the 
patent  ductus  venosus  arantii  has,  also,  many  arguments  against  it.  The 
theory  of  a  passing  anomaly  of  liver  function,  on  account  of  which  the  bile 
not  only  passes  into  the  bile  capillaries,  but  is,  in  part,  also  secreted  into  the 


Fio    31. — Urinary  sediment  in  icterus  neonatorum  (Berlin  Children's  Asylum). 


blood,  is  a  more  probable  one.  Obstruction,  causing  the  flow  of  the  bile  in 
the  wrong  direction,  has  been  attributed  to  increased  pressure  in  the  bile 
capillary  system,  secondary  to  polycholia  or  to  an  excessive  viscosity  of  the 
bile.  But  this  theory,  also,  has  to  be  abandoned,  when  Hirsch  and  Ylppo 
were  able  to  show  that  during  the  last  months  of  fetal  life  an  increase  in  the 
production  of  bile  pigment  and  its  presence  in  the  blood  occurs  normally,  a 
condition  which  persists  for  several  days  after  birth.  Accordingly,  icterus 
neonatorum  may  be  considered  an  actually  physiologic  phenomenon.  Ic- 
terus of  the  skin  always  occurs  when  the  bile  pigment  content  of  the  blood 
passes  a  certain  definite  limit.  The  explanation  of  this  increase  of  the  bili- 
rubin  during  the  first  few  days  of  life  still  remains  a  problem. 

Other  forms  of  icterus  also  occur  in  the  new-born,  which  are  all  the  more 
important  because  they  are  more  serious.    In  all  these  forms  bile  pigments 


DISEASES  OF  THE  NEW-BORN  153 

may  be  found  dissolved  in  the  urine  and  examination  of  the  urine  is,  there- 
fore, very  important  in  the  diagnosis.  The  most  common  of  these  forms  of 
jaundice  is  septic  icterus.  Infectious  forms  are  seen  in  hospitals  and  are, 
at  times,  epidemic.  They  produce  slight  fever  and  gastro-intestinal  symp- 
toms, and  in  some  cases,  are  fatal.  They  probably  depend  upon  an  entero- 
genous invasion  of  bacilli  into  the  bile  passages  ("maladie  bronzee"). 
Congenital  atresias  of  the  large  bile  ducts  are  evidenced,  during  the  first 
days  of  life,  by  the  jaundice  that  they  cause. 

Habitual  icterus  gravis  of  the  new-born  is  a  rare  and  puzzling  condition. 
It  affects  several  or  all  the  children  of  a  family.  It  runs  its  course  with 
severe  general  manifestations  and,  later,  develops  cholemic  symptoms. 
Usually,  it  has  a  fatal  termination.  At  autopsy,  internal  hemorrhages, 
small  serous  exudates  in  the  body  cavities,  swelling  of  the  spleen  and  liver, 
together  with  marked  icteric  discoloration  of  the  brain  nuclei,  are  found. 

EDEMA  AND  SCLEREDEMA  OF  THE  NEW-BORN 

Mild  forms  of  edema  occur  so  much  more  commonly  in  the  feeble  new- 
born, and  especially  in  prematurely  born  infants,  than  they  do  in  older 
children,  that  the  term  edema  neonatorum  has  been  bestowed  upon  them. 
Such  edema  is  not  associated  with  nephritis,  but  resembles  in  its  course  the 
idiopathic  edema  which  is  not  infrequently  seen  in  cachectic  children,  during 
the  first  and  second  years  of  life,  and  is  dependent  upon  the  retention  and 
non-excretion  of  water  which  is,  in  turn,  related  to  disturbances  of  salt 
metabolism.  It  is  apt  to  be  most  severe  when  the  diet  contains  much  salt 
and,  especially,  sodium  salts.  While  this  idiosyncrasy  comes,  in  the  older 
child,  in  the  path  of  disturbances  of  nutrition  and  as  a  consequence  of  infec- 
tion, in  the  new-born  and  prematurely  born  it  represents  a  congenital  func- 
tional insufficiency.  It  is  possible  to  build  up  the  infant  by  proper  care  and 
feeding,  the  edema  disappears  spontaneously. 

Scleredema. — The  hard  swelling  of  scleredema  which  cannot  be  easily 
indented  and,  in  extreme  degree,  may  cause  a  stiffness  of  the  limbs,  is  in 
direct  contrast  to  the  soft  doughy  swelling  of  edema.  The  skin,  in  this  form 
of  disease,  has  a  death-like  pallor  or  is  mottled  and  characteristically  cold. 
The  general  body  temperature  is  far  below  normal.  At  autopsy,  the  sub- 
cutaneous tissue  and  the  skin  are  saturated  with  a  yellowish  fluid,  very  rich 
in  protein,  and  possessing  the  characteristics  of  serum,  rather  than  of  the 
lymph  of  simple  edema.  The  skin  change?  usually  begin  in  the  legs  and 
in  severe  cases  spread  over  the  entire  body,  leaving  only  the  scrotum,  the 
knuckles  and  the  eyelids  unaffected.  The  disease  is  always  accompanied  by 
evidences  of  extreme  weakness,  such  as  apathy,  somnolence,  thready  pulse, 
superficial  and  irregular  breathing,  and  anorexia.  The  prognosis,  usually 
unfavorable,  is  dependent  upon  the  severity  of  these  general  symptoms; 
although  it  is  occasionally  possible  to  save  even  apparently  hopeless  cases 
by  an  improvement  of  their  general  nutritive  condition. 

Schlerema. — The  dieease  must  be  differentiated  from  fatty  sclerema, 
in  which  the  swelling  cannot  be  indented  and  depends  upon  a  hardening 


154  TEXT-BOOK  OF  PEDIATRICS 

of  the  subcutaneous  fat.  As  a  rule,  fever  is  present  in  this  disease.  At 
autopsy,  no  fluid  appears  upon  section. 

The  cause  of  scleredema  has  not  been,  as  yet,  fully  explained.  The  most 
commonly  discussed  hypotheses  are  those  on  the  one  hand,  which  look  upon 
the  condition  as  a  septic  infection,  complicated  by  vascular  changes;  and, 
on  the  other  hand,  as  an  idiopathic  edema  to  which  is  added  a  hardening  of 
the  subcutaneous  fat,  ordinarily  occurring  after  death,  but  which  in  this  case 
is  due  to  a  lowered  metabolism  and  to  the  extreme  cooling  of  the  body.  In 
view  of  the  peculiar  consistency  of  the  exudate,  a  condition  related  to  a 
coagulative  edema,  resulting  from  injury  to  the  vessels  because  of  the  ex- 
tremely low  temperature,  must  also  be  thought  of. 

The  treatment  consists  of  the  application  of  external  heat  by  means  of 
the  incubator,  or  other  similar  apparatus  (see  page  122).  Heat  may  be 
applied  more  rapidly  by  a  hot  bath.  All  further  therapy  must  be  ad- 
dressed to  the  restoration  of  the  reduced  strength.  Feeding  with  mother's 
milk  is  indispensable. 

ALBUMINURIA 

Albuminuria  (proteinuria) ,  is  observed  so  frequently  in  the  new-born 
that  it  has  been  called  "physiologic."  The  quantity  of  protein  is  always 
small.  The  greatest  amount  is  present  from  the  first  to  the  third  day. 
Traces  are  often  present  until  the  second  week  and  occasionally  later.  The 
urinary  sediment  contains  epithelia,  leucocytes,  and  abundant  urates. 

In  spite  of  much  discussion,  the  cause  of  the  albuminuria,  is  not  defi- 
nitely known.  It  is  generally  looked  upon  as  incident  to  the  sudden  changes 
in  the  infant  metabolism  and  circulation  in  the  transition  from  intra-  to 
extra- uterine  life.  Probably  the  physiologic  congestion  arising  in  the  vascu- 
lar system,  during  birth,  causes  proteinuria,  as  it  does  in  the  analogous  con- 
dition of  orthostatic  albuminuria. 

URIC  ACID  INFARCTS 

The  peculiar  change  of  the  kidney  in  which  yellowish-red  stripes  are 
seen  arising  from  the  papillae,  passing  into  the  pyramids  and  disappearing 
in  the  cortex,  is  called  uric  acid  infarct.  Microscopically,  urates  are  found 
imbedded  in  the  kidney  substance.  Doubtless  there  is  an  increased  secre- 
tion of  uric  acid  in  the  new-born.  This  is  most  probably  due  to  the  de- 
composition of  large  numbers  of  nuclein-bearing  cells  (leucocytes).  Why 
the  uric  acid  should  be  deposited  in  the  form  of  infarcts  is  still  an  un- 
solved problem. 

Gradually,  during  the  first  two  weeks  of  life,  the  infarct  is  dissolved 
without  injury  to  the  infant  and  gives  the  urine  its  characteristic  sediment, 
a  reddish-yellow,  finely  granular  mass  which  stains  the  diaper  red  and  is 
seen  under  the  microscope  to  be  made  up  of  casts  covered  with  urates,  fine 
urate  deposits  and  epithelium. 

VAGINAL  HEMORRHAGE 

In  rare  cases,  hemorrhage  from  the  vagina,  of  slight  degree,  occurs  in 
new-born  infants  during  the  first  few  days  of  life.  The  blood  comes  from' 


DISEASES  OF  THE  NEW-BORN  155 

the  uterus,  as  may  be  readily  seen  with  an  ear  speculum.  No  other  symp- 
tom or  disturbance  of  the  general  health  appears. 

Only  recently  has  a  knowledge  of  the  cause  of  this  phenomenon  been 
gamed.  It  is  probably  incident  to  a  physiologic  congestion,  resulting  in 
subepithelial  hemorrhages  of  the  uterus  like  the  process  of  menstruation; 
and  like  it,  caused  by  a  specific  internal  secretion  which  circulates  in  the 
maternal  blood  and  occasionally  passes  into  the  blood  of  the  child  in  suf- 
ficient quantity  to  become  active. 

In  its  differential  diagnosis,  malignant  new  growths  and  septic  diseases 
must  be  taken  into  consideration.  Precocious  menstruation  does  not  need 
to  be  considered,  because  it  hardly  ever  occurs  in  the  first  few  days  of  life. 


n. 

PATHOLOGICAL  CHANGES  OF  THE  BLOOD 
AND  BLOOD-FORMING  ORGANS 


CONSTITUTIONAL  ANOMALIES  AND  DISEASES 
OF  METABOLISM 

BY 
M.  von  PFAUNDLER, 

Munich. 

REVISED  BY 

M.  D.  OTT,  M.D., 

Associate  in  Pediatrics,  University  of  Minnesota. 

INTRODUCTION 
PHYSIOLOGY  AND  PATHOLOGY  OF  THE  BLOOD 

HUMAN  blood-cells,  as  shown  in  the  table  formulated  by  Schridde 
(Figs.  32  and  33)  belong  to  two  different  groups  or  families.  Those  espe- 
cially interested  are  referred  to  the  excellent  article  by  the  above  named 
author  in  Aschoff's  Text-book  of  Pathological  Anatomy  (5th  Edition). 

1.  The  Myelotic  Parenchyma. — In  embryos  of  less  than  10-12  cm.  in 
length  only  the  primary  erythroblasts  are  found  in  the  blood-spaces.  Only 
at  a  later  date  do  the  other  derivatives  of  the  cells  of  the  vessel  walls  appear 
and  then,  extiavascularly,  only  in  the  liver  but  after  the  second  month  of 
fetal  life  also  in  the  spleen  and  bone-marrow,  the  latter  gradually  monopo- 
lizing the  formation  of  these  cells.    From  the  blood  forming  parenchyma, 
the  white  cells  enter  the  blood  stream  by  their  own  activity,  while  the  red 
corpuscles  are  forced  in  by  the  rupture  of  the  centre  when  the  cells  have 
matured.    The  platelets  are  derived  from  the  giant  cells. 

2.  The  Lymphatic  or  "Non-granular"  Parenchyma. — The  cells  of  the 
walls  of  the  lymph-vessels,  together  with  the  germinal  centres  of  the  lymph 
nodes  form  the  lymphatic  parenchyma  which   appears  later  than  the 
''granular  parenchyma."    The  genealogy  of  the  large  mononuclear  leuco- 
cytes is  still  in  dispute. 

At  birth  the  greater  portion  of  the  myelotic  parenchyma  is  confined  to 
the  grayish-red,  functionally-active  bone-marrow  and  the  lymphatic  paren- 
chyma is  found  in  the  lymph  nodes,  the  spleen,  and  other  lymphoid 
tissues  of  the  body.  In  the  long  bones  this  functionally  active  marrow  later 
changes  into  inactive,  yellow,  fatty  and  gelatinous  marrow.  Under  patho- 
logic conditions  a  return  to  the  phase  of  widely  diffused  blood-forming 
parenchyma  is  seen,  accompanied  by  the  appearance  of  atypical  forms  of 
cells.  Retrograde  changes  of  an  embryonic  character,  especially  in  the 
direction  of  a  reversion  to  a  gelatinous  bone-marrow,  is  also  observed.  Both 
of  these  tendencies  carry  with  them  stimuli  of  varying  nature  and  intensity 
156 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS 


157 


Even  the  ordinarily  adequate,  regulative  stimulus,  incident  to  the  normal 
breaking  down  of  the  blood  elements,  may  become  pathologic  in  degree  if 
this  degeneration  is  marked.  Furthermore,  the  development  of  endogenous 
and  ectogenous  poisons,  the  nature  of  which  is  not  fully  understood,  must  be 


considered  productive  of  non-physiologic  stimuli.  The  return  to  the 
embryonic  type  of  blood  formation,  that  is,  an  activation  of  the  myelotic 
blood-forming  foci  outside  of  the  bone-marrow,  occurs  more  readily  in  chil- 
dren than  in  adults. 

The  Blood  in  Childhood. — The  most  important  peculiarities  of  the  child 's 
blood,  as  compared  with  that  of  the  adult,  are  given  in  the  following  table: 


158 


TEXT-BOOK  OF  PEDIATRICS 


Cells  per  Cm. 
of  Blood 

Reds 
(Million) 

Whites 
(Thousands) 

Percentage  of  various  forms  of  whites 

Hemo- 
globin 
(Sahli) 

Polymorpho- 
nuclear 

Large 
Mono- 
nuclear 

Lympho- 
cytes 

Neutro 

Eosino 

New-born  

5-7 
4.1-5.2 
4.5-5.0 

20-32 
8-13 
6-8 

70 
27-36 
71 

2 

2-7 
3 

8 
9-15 

4 

19 
50-55 
22 

110-130 
60-80 
100 

Infant  

Adult  

The  following  facts  may  be  added  by  way  of  histologic  description : 
Erythroblasts,  nucleated  red  cells,  are  frequently  found  during  the  first 
few  days  after  birth  and  occasionally  even  later  during  the  first  half-year 


Cell  of  Lymph-vessel  wall 


Lymphocyte 


Lymph  oblast 


Lymph  oblastic 
Plasma-cell 


Lymphocyte 


Lymphocytic 
Plasma-cell 


FIG.  33. — Lymphatic  tissue    (representing  stain  with  Azur  II-Eosin). 
(From  Schridde  in  Aschoff's  Text-book  of  Pathologic  Anatomy.) 

in  healthy  infants.  An  excess  of  the  non-granular  over  the  granular  types 
of  leucocytes  persists  until  the  fifth  year.  At  this  age  the  proportions 
existing  in  the  adult  are  rapidly  approached.  Large  forms  are  remarkably 
frequent  among  the  non-granular  cells  in  childhood.  During  the  first  few 
weeks  an  occasional  myelocyte  is  found  in  the  normal  blood.  Immature 
cells  are  frequently  found  in  the  blood  of  normal  infants  during  the  first 
weeks  of  life;  as,  in  the  event  of  any  disturbance  of  hematopoiesis ,  they  oc- 
curmorecommonlyinthe  blood  stream  of  children  than  in  that  of  later  years. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  159 

Hemodynamics. — The  pathologic  phenomena  attendant  upon  diseases 
of  the  blood  are  much  better  understood  than  formerly  as  a  result  of  recent 
discoveries  and,  particularly,  of  those  of  Plesch. 

The  functional  ability  of  each  organ,  as  of  the  body  in  general,  is  first  of 
all  dependent  upon  its  oxygen  supply,  which  represents  the  most  important 
function  of  the  blood  and  the  circulation.  According  to  Plesch,  the  oxida- 
tion process  in  the  tissues  is  the  main  and  the  only  indication  of  the  vigor  of 
the  circulation.  If  the  oxygen  requirement  is  increased  as  a  result  of  en- 
larged functional  activity,  as,  for  instance,  of  the  musculature  in  bodily 
exercise,  this  increased  demand  may  be  satisfied  by  an  increase  of  the  vol- 
ume of  blood  per  minute.1  This  result  may  be  attained  by  increase  either 
of  the  force  or  the  rate  of  the  heart  beat,  or  by  increased  velocity  of  the 
blood  flow.  The  demand  may  otherwise  be  met  by  more  complete  oxygena- 
tion  of  the  blood,  by  the  increased  oxygen-carrying  power  of  the  blood,  by 
improved  pulmonary  aeration,  or  by  the  more  complete  interchange  of 
gases  between  the  blood  and  the  tissues.  These  factors  are  very  closely 
interdependent  and  the  laws  which  govern  these  many-sided  functions 
frequently  find  expression  in  the  symptomatology  of  the  diseases  of  the 
blood  and  circulatory  apparatus.  If  an  injury  alters  one  of  these  factors, 
compensatory  changes  in  the  other  factors  usually  appear.  If,  for  example, 
the  oxygen  capacity  of  the  blood  is  reduced  as  a  result  of  a  loss  of  hemo- 
globin, the  volume  of  blood  per  minute  will  increase.  When  the  blood 
volume  is  increased  by  added  force  of  the  heart -beat,  resulting  in  complete 
systolic  emptying  of  the  heart  and  greater  heart  capacity,  palpitation, 
anemic  dilatation  and  hypertrophy  will  arise.  If  the  increase  is  brought 
about  by  added  frequency  of  heart  action,  an  anemic  tachycardia  will 
develop;  while  increased  velocity  will  result  in  hemic  murmur  ("bruit  de 
diable")-  The  oxygen  demand  of  the  anemic  patient  is  proportional  to  the 
increased  amount  of  respiratory  and  circulatory  work  required  to  compen- 
sate the  low  hemoglobin.  E.  Mueller's  studies  have  confirmed  in  many 
cases  the  application  of  the  hemodynamic  laws  operative  in  the  adult  to 
the  child. 

A.  GROUP  OF  ANEMIAS 
GENERAL  SYMPTOMATOLOGY 

The  conditions  grouped  under  this  head  are  very  often  secondary  or 
associated  manifestations  of  other  disturbances.  They  are  characterized,, 
clinically,  by  a  reduction  in  the  total  quantity  of  blood,  by  an  absolute 
or  relative  decrease  of  the  erythrocytes  or  of  hemoglobin,  with  habitual 
pallor  of  the  skin  and  mucous-membranes,  and  by  compensatory  and 
hemodynamic  adjustments  resulting  from  them.  The  reduction  of  the 
hemoglobin  index  which  indicates  an  oligochromemia,  that  is,  a  diminu- 
tion of  the  total  amount  of  hemoglobin  in  the  blood,  serves  at  present  as 

1  By  volume  per  minute  is  meant  the  amount  of  blood  which  enters  one  chamber  of 
the  heart  in  one  minute,  or  which  passes  through  the  total  area  of  the  greater  or  lesser 
circulation. 


160  TEXT-BOOK  OF  PEDIATRICS 

a  criterion  which  may  be  readily  applied.  It  is  a  misleading  one,  however, 
when  the  volume  of  the  blood  is  changed  as  in  hydremia  or  in  over-concen- 
tration. The  total  quantity  of  blood  and  the  total  quantity  of  hemoglobin 
can  be  determined  in  the  living  in  only  exceptional  cases. 

Even  though  the  common  term  anemia  suggests  a  reduction  of  the  total 
volume  of  blood,  or  at  least  a  diminution  of  the  essential  constituents  of  the 
entire  blood,  nevertheless  it  must  be  borne  in  mind,  in  dealing  with  the 
individual  case,  that  it  is  not  merely  a  question  of  the  quantity  of  the  blood, 
but  rather  one  of  its  functional  capacity.  The  term  "thin-blooded"  more 
nearly  covers  the  facts  of  such  functional  poverty.  It  is  clear  that  even 
though  it  be  diminished  in  quantity,  the  blood  may  be  functionally  effi- 
cient as  an  agent  of  circulation  and  interchange,  because  it  can  move  more 
rapidly  and  thus  increase  its  specific  activity.  In  such  cases  we  speak  of 
a  compensated  anemia.  Attention  has  been  called,  under  the  head  of 
hemodynamics,  to  the  various  mechanisms  of  these  very  frequent  adjust- 
ments. Frequently  compensation  is  established  by  the  fact  that  the  anemic 
blood,  in  itself,  has  the  power  to  stimulate  the  formation  of  red  blood-cor- 
puscles. This  stimulus  naturally  operates  in  those  regions  in  which  the 
myelotic  parenchyma  persists  after  birth,  viz.,  in  the  functionally  active 
bone-marrow.  But,  under  certain  circumstances,  it  may  become  active  in 
those  organs  which  do  not  participate  in  the  erythropoietic  function  in  post- 
natal life,  as,  for  instance,  in  the  lymph  nodes,  the  spleen,  and  the  liver,  in 
which  the  myelotic  parenchyma  may  be  newly  formed.  Not  only  in  loca- 
tion, but  also  in  method,  such  a  compensatory  erythropoiesis  may  or  may 
not  be  analogous  to  the  normal  developmental  process.  A  postembryonic 
type  of  compensatory  erythropoiesis  may  usually,  in  fact,  be  distinguished 
from  the  embryonic  form.  In  the  latter  type,  the  immature  cells,  as  megal- 
ocytes  and  megaloblasts,  which  physiologically  are  found  only  in  the  blood 
of  the  embryo,  at  once  appear  in  the  blood  stream.  In  the  postembryonic 
phase,  however,  this  occurs  only  in  extreme  cases  and  as  a  final  effort  in  the 
blood-forming  function  of  the  bone-marrow.  Since  an  actual  transition  to 
the  embryonic  type  is  probably  not  determined  by  qualitative,  but  rather 
by  quantitative  conditions,  and  is  further  influenced  by  age,  in  childhood  at 
least,  it  will  hardly  serve  in  itself  to  differentiate  the  several  forms  of  anemia. 
The  erythropoietic  stimuli,  activated  by  anemia,  will  not  exercise  any 
noticeable  compensatory  influence  if  the  requirements  for  successful  erythro- 
poietic activity  are  wanting  from  the  beginning. 

Pathologic  changes  in  the  erythropoietic  tissues  in  anemia  cannot 
always  be  determined  by  the  methods  in  use  today. 

Every  systematic  classification  of  the  anemias  of  childhood  meets  with 
objections  in  the  present  status  of  our  knowledge  of  the  subject.  The  di- 
dactic and  practical  purpose  of  this  work,  however,  makes  such  a  classifi- 
cation necessary.  Such  presentation  of  the  nature  of  these  diseases  as  our 
present  knowledge  will  permit  will  give  the  thoughtful  physician  basis  for 
a  logical  therapy. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  161 

I.  ANEMIA  DUE  TO  PRIMARY  INTERFERENCE 
WITH  ERYTHROPOIESIS. 

This  form  of  anemia  is  characterized  by  an  insufficiency  in  the  blood- 
forming  organs  incident  either  to  hypoplasia  of  the  matrix,  external  con- 
ditions unfavorable  to  its  normal  activity,  or  to  a  lack  of  raw  materials.  Its 
clinical  characteristics  are  chiefly  of  a  negative  sort.  The  signs  and  symp- 
toms of  increased  destruction  of  the  erythrocytes  in  the  blood  are  not 
evident,  nor  are  theie  indications  of  either  an  excessive,  an  atypical,  or  an 
incomplete  erythropoiesis.  Actual  changes  in  the  total  quantity  of  the 
blood,  oligemia,  hydremia,  oligocytosis,  oligochromemia  and,  occasionally, 
polychromasia,  and  the  more  marked  variations  in  the  size  of  the  red  cells, 
are  alone  met  with. 

1.  Congenital  or  Early  Acquired  Anergic  and   Aplastic    Anemias. — 
In  this  group,  which  has  been  little  studied,  insufficiency  of  erythropoiesis 
is  the  result  of  anomalies  in  the  formation  or  function  of  the  bone-marrow. 

Hypoplastic  marrow  is  not  uncommon  in  anemic  infants,  nor  is  a  fatty 
marrow  in  the  long  bones  of  children  even  in  the  first  two  years.  The 
latter  finding  is  considered  to  be  the  basis  of  the  anemia  seen  in  congenital 
myxedema  and  symptomatically  related  conditions. 

Anemias  appearing  early  in  cases  of  infantilism,  with  hypoplasia  of  the 
genitalia  and  the  circulatory  system,  in  which  the  blood  findings  so  much 
resemble  those  of  chlorosis  that  they  have  been  erroneously  regarded  as 
habitual  or  chronic  chloroses,  probably  belong  in  this  group.  Benjamin  has 
recently  reported  a  peculiar  type  of  anergic  anemia,  with  hypoplastic  habi- 
tus and  mental  weakness,  in  which  no  acquired  injuries  could  be  demon- 
strated and  in  which  both  therapeutic  results  and  anatomic  findings  in  the 
bone-marrow  were  negative.  In  this  case,  probably,  the  anemia  may  be 
considered  the  result  of  a  congenital  functional  weakness  of  the  hematopoi- 
etic  mechanism.  Similar  anomalies  of  development,  complicating  such 
cases,  are  found  in  other  organs. 

2.  Alimentary  Anemia  (in  the  restricted  sense). — Experimental  starva- 
tion and  states  of  inanition,  resulting,  either  from  stenoses  along  the  ali- 
mentary tract  or  from  internal  causes,  do  not  produce  an  anemia  but  rather 
an  atrophy  of  the  blood  which  parallels  that  of  the  remainder  of  the  body. 
In  young  rapidly  growing  animals,  on  the  other  hand,  a  diet  poor  in  iron 
impairs  erythropoiesis  through  a  deficiency  in  the  material  for  the  synthesis 
of  hemoglobin.    Von  Hoesslin  and  others  have  observed  that  children  who 
have  been  fed  exclusively  upon  milk2  or  other  foods  deficient  in  iron  be- 
come anemic  after  the  initial  store  in  the  liver  has  been  exhausted.    This 
is  especially  true  in  the  case  of  premature  infants,  twins,  and  children 
born  of  anemic  mothers.    This  so-called  chlorotic  anemia  of  the  new-born 
described  by  the  French  authors,  better  termed  oligosideremia,  offers  a  good 
prognosis  and  responds  quickly  to  the  administration  of  iron.    That  not  all 
premature  infants  develop  this  anemia  can  be  explained  by  the  fact  that 
the  initial  store  of  iron  is  quite  a  variable  quantity  even  in  full  term  infants. 

2  Whole  cow's  milk  contains  0.3-0.7  milligram  Fe2O2  and  human  milk  1.5-2  milli- 
grams per  litre. 
11 


162  TEXT-BOOK  OF  PEDIATRICS 

As  in  other  forms  of  anemia,  the  constitutional  factor  must  be  considered 
in  the  pathogenesis  of  alimentary  anemia  without,  however,  invalidating 
the  meaning  of  the  term.  Children  of  this  type  have  a  higher  iron  require- 
ment than  normal  children,  as  Schwartz  and  Rosenthal  have  recently 
demonstrated  that  they  have  a  negative  iron  balance.  There  are,  of  course, 
other  factors  to  be  considered,  but  these  are  discussed  elsewhere.  Even  in 
older  children  who,  from  some  psychic  or  other  causes,  subsist  solely  on  milk 
may  show  a  reduction  of  the  color  index  without  other  appreciable  blood 
changes.  The  observations  of  M.  B.  Schmidt  that  in  pregnant  animals  an 
iron  poor  diet  retards  the  growth  of  theoffspringis  noteworthy  in  this  respect. 

The  form  of  alimentary  anemia  described  by  Czerny  and  his  followers 
belongs  in  another  category.  According  to  their  conception,  a  high  milk 
diet  produces  in  certain  constitutionally  predisposed  children  actual  changes 
in  the  blood  and  blood-forming  organs  through  the  action  of  the  milk  fat, 
particularly  the  fatty  acids.  Whether  these  substances  affect  the  blood 
through  a  withdrawal  of  alkalies  or  through  some  hemolytic  action 
(Kleinschmidt),  these  anemias  should  be  classified  with  those  of  toxic  ori- 
gin. This  view  is  supported  by  the  symptomatology  of  the  severe  cases 
as  well  as  to  their  failure  to  respond  to  ordinary  iron  medication. 

3.  The  So-called  Anemia  of  Poverty;  Tenement  Anemia;  School 
Anemia;  Incubator  Anemia. — It  is  certain  that  children  reared  in  city 
slums,  that  is,  in  overcrowded,  poorly  ventilated,  ill-lighted,  cold  and  damp 
dwellings,  who  are  taken  into  the  open  but  rarely,  and  who  with  poor  food 
find  only  an  ineffective  stimulus  to  physical  exercise,  not  only  appear  pale 
and  weak,  but  often  suffer  from  actual  anemia.  From  the  further  obser- 
vation that  all  the  objective  symptoms  of  such  an  anemia  disappear  after 
a  few  weeks  or,  at  the  most,  a  few  months  of  living  and  exercise  in  the 
open,  either  in  the  country,  the  mountains,  or  at  the  sea-side,  we  may 
conclude  that  some  one  of  these  many  injurious  elements,  or  their  com- 
bination, has  had  an  unfavorable  influence  upon  the  formation  of  red  blood- 
corpuscles.  These  children,  almost  without  exception,  become  rickitic 
during  the  first-half  of  the  third  year  and  are  infected  with  tuberculosis  by 
the  tenth  year.  These  forms  of  anemia  do  not,  however,  appear  to  be 
dependent  upon  these  very  common  diseases  or  upon  any  disease  of  other 
organs  or  systems. 

To  this  group  should  be  added  the  anemia  of  debilitated  infants  who  are 
treated  for  too  long  a  time  in  the  incubator,  a  form  which  reacts  very  fav- 
orably to  fresh  air  treatment. 

The  attempt  has  been  made  several  times,  but  without  definite  results 
up  to  the  present  time,  to  gain  a  clearer  knowledge,  by  means  of  natural  or 
artificial  experiments  on  human  beings,  animals  and  plants,  of  the  particu- 
lar form  of  injury  which  produces  anemia  and  of  its  method  of  action.  It  is 
true  that  the  absence  of  light  causes  a  loss  of  chlorophyll,  which  is  the 
analogue  of  hemoglobin.  In  a  purely  experimental  way,  however,  relative 
darkness,  as  experienced  in  the  polar  night,  in  mining  operations,  or  in 
animals  kept  in  covered  cages,  does  not  cause  any  reduction  of  hemoglobin 
in  adult  human  beings  or  animals,  or  at  least  no  relative  oligochromemia 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  163 

or  oligocytosis.  Just  the  reverse  might  rather  be  expected  from  a  reduction 
of  the  oxygen  tension  and  the  poor  decarbonization  of  the  blood.  It  is 
possible  that  the  red  blood-cell  formation  of  the  growing  organism  responds 
more  acutely  to  such  injuries  and  especially  to  the  absence  of  actinic  and 
related  stimuli  (Schoenenberger).  The  increased  circulation  in  the  muscu- 
lature and  in  the  skin  during  exercise  in  the  open,  and  especially  in  moving 
air,  with  direct  or  indirect  daylight,  and  the  resultant  breaking  down  of  the 
erythrocytes,  probably  begets  erythropoietic  stimuli,  which  are  never 
absent  during  the  developmental  period,  especially  in  constitutionally  weak 
children,  without  resulting  injury. 

In  these  anemics  a  rather  mild  degree  of  anisocytosis,  and  oligochro- 
memia,  moderate  oligocytosis  and,  occasionally,  polychromatophilia, 
combined  with  the  general  symptoms  of  anemia  or  chlorosis,  such  as  head- 
ache, sleeplessness,  anorexia,  general  weakness,  palpitation  of  the  heart, 
listlessness,  etc.,  are  observed.  A  special  tendency  to  obstipation,  indi- 
canuria,  intermittent  albuminuria,  and  vomiting  is  also  to  be  noted.  In- 
creased area  of  heart  dulness  and  accidental  murmurs  are  almost  the  rule  in 
school  anemias.  There  is  no  fever  and  the  prognosis  is  favorable. 

4.  Chlorosis,  or  Green  Sickness,  and  Pseudochlorotic  Conditions. — 
These  disturbances  almost  always  begin  during  or  immediately  after 
puberty.  They  are  not  really  children's  diseases  and,  therefore,  they  will 
not  be  fully  considered  here.  Nevertheless,  chlorosis  maybe  properly 
included  in  the  symptomatic  grouping  of  anemias,  since  while  many  cases 
have  a  normal  hemaglobin  content  and  exhibit  certain  signs  and  symptoms 
common  in  chlorosis,  that  are  not  due  to  anemia  (Morawitz),  yet  the 
absence  of  all  evidences  of  an  increased  breaking  down  of  the  red  blood-cells 
shows  that  there  is  an  insufficiency  of  erythropoiesis  and  that  the  chief 
factor  in  the  causation  of  the  anemia  is  usually  a  limitation  upon  the  pro- 
duction of  new  hemoglobin. 

Nature  and  Etiology. — The  characteristic  blood  findings  of  chlorotic 
anemia  are  confined  to  a  reduction  of  the  coloring  matter  of  the  blood,  that 
is,  to  an  oligochromemia,  without  a  corresponding  oligocytosis.  It  has  been 
shown,  also,  that  the  total  quantity  of  blood,  as  indicated  by  the  total 
number  of  erythrocytes,  where  the  red  cell  count  is  normal,  is  not  reduced 
but  usually  increased.  This  increase  may  amount  to  almost  double  the 
normal  quantity,  so  that  the  blood  represents  ten  per  cent,  of  the  body- 
weight  instead  of  about  five  per  cent.  It  is  permissible,  therefore,  to  speak  of 
a  chlorotic  plethora.  The  production  of  hemoglobin  does  not  seem  able  to 
keep  up  with  this  increase  of  blood.  The  cause  of  the  plethora  is  in  doubt. 
Whether  it  represents  a  pathologic  survival  of  the  blood  proportions,  rang- 
ing from  six  to  eight  per  cent,  of  the  body-weight,  which  exist  before 
puberty;  whether  it  is  dependent  upon  a  tendency  to  high  water  retention 
in  the  chlorotic,  or  whether  it  may  be  regarded  as  an  attempt  at  compen- 
sation of  the  reduced  oxygen  capacity  of  the  blood,  is  not  determined. 
Another  viewpoint  from  which  the  nature  of  chlorosis  may  be  considered  is 
suggested  by  the  fact  that  the  disease  occurs  almost  exclusively  in  females 


164  TEXT-BOOK  OF  PEDIATRICS 

and  at  puberty,  and  that  supposedly  it  has  a  subsequent  effect  upon  the 
generative  organs. 

Symptoms. — In  a  majority  of  cases  the  only  definite  blood  changes  are 
oligochromemia,  anisocytosis,  polychromatophilia,  slight  oligocytosis, 
general  pallor,  reduction  of  the  color  index  of  the  red  cells,  diminution  of  the 
specific  gravity  of  the  blood,  increased  coagulability,  and  a  decrease  of  the 
blood-platelets.  The  subjective  symptoms  are  sleepiness,  lassitude, 
migraine-like  headache,  dizziness,  shortness  of  breath,  palpitation  of  the 
heart,  fainting  spells,  side-stitch,  epigastric  pain,  chills,  blinking,  tinnitus, 
dyspepsia,  anorexia  and  parorexia,  dysmenorrhea,  and  leucorrhcea.  The 
objective  symptoms  consist  chiefly  in  a  greenish  or  alabaster  pallor,  in 
slight  edema  and  the  formation  of  venous  thromboses,  both  of  which  are 
known  to  occur  in 'the  mesentery;  in  increased  area  of  heart  dulness,  an 
exaggerated  cardiac  impulse,  accidental  heart  murmurs,  venous  bruit,  and 
softness  and  frequency  of  the  pulse;  in  tachypncea,  gastroptosis,  moderate 
hyperchlorhydria,  and  occasionally  enlargement  or  descent  of  the  spleen. 
No  characteristic  changes  of  metabolism  are  known. 

Diagnosis. — The  blood  findings  are  pathognomonic.  Certain  negative 
findings  and  the  reduction  of  the  color  index  are  important  in  differential 
diagnosis.  Pseudo-anemia,  is  often  mistaken  for  chlorosis.  Secondary 
anemia  of  toxic  origin  or  following  hemorrhage  may  also  cause  confusion. 

II.  ANEMIAS  DUE  TO  LOSS  OF  BLOOD 

In  this  class  of  cases,  in  addition  to  the  blood  findings  of  the  first  group 
incident  to  a  relative  insufficiency  of  erythropoiesis,  the  evidences  of  stim- 
ulation, in  the  presence  of  normoblasts,  of  poikilocytosis  and  leucocytosis, 
are  found. 

Post-hemorrhagic  anemia,  especially  in  traumatic  cases,  is  a  condition 
the  etiology  of  which  is  considerably  more  clear  than  in  other  groups  of 
anemias  and  in  its  purely  experimental  pathology  is  very  instructive. 
Immediately  after  an  external  or  internal  hemorrhage  has  occurred,  an 
actual  diminution  of  the  total  quantity  of  blood,  that  is,  a  true  oligemia  is 
always  found.  In  individual  cases  this  is  rapidly  compensated,  but  in  cases 
where  hemorrhage  is  frequent  or  habitual  it  persists,  and  the  proportion  of 
blood  per  kilo  of  body-weight  may  be  reduced  from  60  c.c.  to  about  20  c.c. 
The  first  attempt  at  repair  after  a  hemorrhage  is  an  increase  of  the  volume 
of  the  remaining  blood  by  withdrawal  of  plasma  from  the  tissues.  This 
serves  to  refill  the  vascular  system  and  to  restore  in  a  degree  the  blood- 
pressure.  It  results  in  hydremia,  oligochromemia,  oligocytosis,  with  normal 
color  index,  and  to  a  certain  extent  in  a  swelling  of  the  red  blood-corpuscles. 
Later,  a  restitution  of  the  blood-cells  occurs.  The  loss  of  blood  gives  an 
intense  stimulus  to  the  bone-marrow  which,  if  it  is  not  already  exhausted, 
results  in  putting  into  circulation  stored  up  mature  cells,  erythrocytes,  and 
neutrophilic  leucocytes  alike ;  and  also  in  the  liberation  of  immature  forms, 
among  them  cells  poor  in  hemoglobin,  nucleated  polychromatic  cells,  baso- 
philic  granular  erythrocytes,  mononuclear  leucocytes  and  myelocytes.  In  a 
word,  a  blood  crisis  obtains.  Secondly,  it  responds  in  an  active  hyperplasia 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  165 

of  the  marrow  tissue  and  in  a  rapid  and  excessive  development  of  erythro- 
cytes  and  granular  leucocytes.  The  formation  of  hemoglobin  is  a  matter  of 
longer  delay.  A  relative  leucocytosis  appears,  although  the  loss  of  leuco- 
cytes is  less  than  that  of  the  erythrocytes,  because  the  former  are  more 
uncommon  in  the  rapid  axial  stream.  A  decrease  of  the  color  index  char- 
acterizes this  stage  of  post-hemorrhagic  anemia.  The  regeneration,  as  a 
rule,  follows  the  type  of  a  postembryonic  erythropoiesis.  One  exception  to 
this,  suggested  by  the  writers'  experience  and  by  experimental  hemor- 
rhagic  anemia  in  animals,  is  found  in  severe  umbilical  hemorrhage  of  the 
new-born.  The  coagulability  of  the  blood  increases  during  and  after  the 
hemorrhage.  Lipemia  and  fatty  infiltration  of  the  tissues  may  occur. 

Causatively,  aside  from  the  trauma,  the  so-called  hemorrhagic  dia- 
theses, Barlow's  disease,  melena,  umbilical  hemorrhage,  epistaxis,  rectal 
polyposis,  certain  intestinal  parasites,  and  the  hemorrhagic  nephritides  must 
be  considered. 

Symptomatically,  large  and  rapid  loss  of  blood  causes  faintness,  pallor, 
general  weakness  and  sometimes  convulsions.  Repeated  small  hemorrhages 
may  produce  cachectic  conditions.  Hemorrhages  are  more  dangerous  in 
children  than  in  adults.  The  rapid  loss  of  from  one-fourth  to  one-third  of 
the  total  quantity  of  blood,  that  is  to  the  extent  of  two  per  cent,  of  the  body- 
weight  is  dangerous  to  life. 

III.  HEMOCYTOLYTIC  AND  MYELOPATHIC  ANEMIAS 

In  this,  the  largest  group  of  anemias,  we  have  to  deal  with  acquired 
conditions,  which  affect,  first,  the  mature  blood  in  the  circulatory  system, 
and,  second,  the  blood-forming  organs.  A  strict  classification  of  cases, 
dependent  upon  the  point  of  attack  of  the  agent  of  injury,  is  neither 
practically  possible  nor  theoretically  justified.  For  when  a  hemic  poison 
enters  the  circulation  it  not  only  prejudices  the  mature  circulating  cells,  but 
it  is  likely  to  extend  its  influence  to  the  blood-forming  parenchyma.  Thus 
a  combination  of  myelogenous  and  hematogenous  injuries  is  formed. 
Chemical  poisons,  such  as  lead,  which  have  a  recognized  specific  toxicity  to 
the  erythrocytes,  have  been  shown,  also,  to  damage  the  bone-marrow. 
Further,  signs  of  blood  degeneration,  by  way  of  the  too  early,  as  well  as  the 
increased  break-down  of  the  circulating  blood-cells,  are  particularly  notice- 
able whenever  weak  cells  appear  in  the  circulation  as  the  result  of  a  myelo- 
genous injury.  Finally,  it  may  be  supposed  that  a  hematoplastic  stimulus, 
such  as  a  marked  degeneration  of  the  mature  cells  would  give  to  the  blood- 
forming  organs,  after  it  has  exceeded  certain  limits,  must  become  patho- 
logic and  harmful.  It  is  a  hopeless  task,  indeed,  to  search  the  pathologic 
blood  for  criteria  which  will  make  a  definite  differentiation  between  myelo- 
genous and  hematogenous  anemia  possible.  Basophilic  granulation  of  the 
erythrocytes,  poikilocytosis,  crenation,  hemosiderosis,  or  the  deposit  in  the 
tissues  of  increased  blood-pigment  from  broken  down  cells,  and  the  evi- 
dences of  reversion  to  the  embryonic  type  of  erythropoiesis,  are  all  impor- 
tant characteristics  of  the  forms  of  anemia  under  consideration.  They  do 


166  TEXT-BOOK  OF  PEDIATRICS 

not,  however,  invite  conclusions  as  to  the  localization  of  the  injury,  whether 
in  the  mature  blood  or  in  the  immature  cells. 

Theoretically,  a  large  part  of  the  anemias  of  this  class  may  be  consid- 
ered, in  the  broadest  sense,  as  toxogenous  anemias;  that  is,  they  are  caused 
by  more  or  less  well  recognized  ectogenous  or  endogenous  blood  poisons. 
In  the  light  of  their  action  two  classes  of  these  may  be  distinguished. 

(a)  Hemocytolytic  poisons  are  those  which  cause  the  intravascular 
dissolution  or  disintegration  of  a  large  number  of  red  blood-cells,  with  cer- 
tain definite  results.  The  coloring  matter  passes  into  the  plasma,  a  hemo- 
globinemia.  A  part  of  it  is  changed  in  the  liver  into  bilirubin  and  urobilin; 
another  part  is  stored  in  the  liver,  spleen,  and  bone-marrow  as  hemosiderin ; 
and  some  is  excreted  by  the  kidneys,  giving  a  hemoglobinuria  or  methemo- 
globinuria.  The  erythrocytic  debris  is  taken  care  of  in  the  spleen,  giving  a 
spodogenous  enlargement  of  the  organ,  and  in  the  blood  by  the  phagocytes. 
This  cleaning  up  process  does  not  always  take  place  without  disturbance, 
by  way  of  destruction  of  the  leucocytes,  intravascular  clotting,  so-called 
hematogenous  icterus,  anuria,  etc. 

In  children  the  ectogenous  substances  which  are  to  be  considered  in  this 
relation  are  certain  sera,  the  primary  toxic  action  of  which  is  to  be  distin- 
guished from  anaphylaxis;  snake  venom,  the  poison  of  bee  stings,  and  vari- 
ous vegetable  poisons,  such  as  aspidium,  the  several  members  of  the 
species  of  solanum,  and  mushrooms.  Among  the  endogenous  hemolytic 
poisons  are  the  poison  arising  from  burns,  the  biliary  constituents  which 
enter  the  blood,  causing  cholemia,  and  particularly  the  microbic  toxins  of 
sepsis,  Winckel's  disease,  malaria,  typhoid  and  scarlet  fever. 

Paroxysmal  hemoglobinuria  is  a  peculiar  disease  caused  by  endogenous 
hemolytic  substances  in  the  nature  of  autolytic  amboceptors.  These  ambo- 
ceptors  are  peculiar  in  that  they  attach  themselves  to  the  erythrocytes,  both 
in  vivo  and  in  vitro,  only  at  low  temperatures,  when  the  natural  complement 
of  the  blood,  which  is  liable  in  these  subjects  to  unusual  variations,  completes 
the  chain  and  permits  the  hemolysis.  This  explains  the  occurrence  of  repeti- 
tional  attacks  of  the  disease.  These  attacks  are  brought  on  by  exposure  to 
cold.  They  begin  their  course  with  chills,  cyanosis,  pain  in  the  back,  hemo- 
globinuria, oligocytosis  and  relative  leucocytosis;  and  they  occasionally  go 
on  to  embolism  with  gangrene.  They  usually  last  from  one  to  two  hours 
and  are  followed  by  jaundice,  enlargement  of  the  spleen,  and  urobilin- 
ogenuria.  The  repeated  appearance  of  these  abnormal  amboceptors  may 
be  closely  related  to  a  lessening  of  the  resistance  of  the  red  blood-cells.  In 
almost  all  of  the  children  so  affected  there  is  a  question  of  the  existence  of 
some  congenital  or  parasyphilitic  poison. 

Hemocytolysis,  with  the  formation  of  methemoglobin,  occurs  with 
many  medicinal  agents,  among  which  are  potassium  chlorate,  the  phenol 
derivatives,  as  acetphenitidin,  lactophenin,  phenocoll,  and  phenolphthalein; 
the  anilin  derivatives,  antifebrin  and  acetanilid,  and  pyrogallol.  Chemical 
changes  in  the  hemoglobin,  involving  its  oxygen  content,  are  caused  by 
carbon  monoxide,  hydrogen  sulphide,  and  hydrocyanic  acid. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  167 

(6)  Other  hemic  poisons  may  cause  early  destruction  of  the  erythrocytes 
without  involving  their  solution  in  the  blood  to  any  great  extent.  These 
injurious  agents  doubtless  act,  in  part,  through  the  liver,  spleen,  and  bone- 
marrow  upon  immature  forms  of  cells.  Hemosiderosis,  the  phagocytosis 
of  red  cells,  and  the  excretion  of  uiobilin  and  urobilinogen  are  observed  in 
these  cases.  Of  the  ectogenous  poisons,  lead,  mercury  and  arsenic  belong 
in  this  class.  Among  the  endogenous  poisons  of  similar  action  are  those 
excreted  from  the  body-substance  of  such  animal  parasites  as  tenia,  bothrio- 
cephalus,  ascarides,  anchylostomata,  and  trichocephalus,  as  well  as  lipoid 
substances  arising  from  degenerated  body  tissues.  To  these  may  be  added 
the  hypothetical  toxins  of  acute  intestinal  disease  and  the  nephroses,  and, 
finally,  the  bacterial  poisons  and  the  reaction  products  they  excite  in  latent 
as  well  as  manifest  tuberculosis  and  syphilis. 

It  was  thought,  because  normally  erythrocytes  are  destroyed  in  the 
spleen,  that  hypertrophy  of  this  organ  led  to  an  increased  destruction  of 
these  cells.  It  is  probable,  however,  that  the  hemolytic  activity  of  the 
spleen  pulp  is  confined  to  those  erythrocytes  which  originally  were  or  have 
become  defective.  According  to  Frank,  the  reticular  endothelial  cells  of  the 
spleen  and  lymph  nodes  elaborate  a  hormone  which  is  inhibitory  to  the 
bone-marrow,  and  which  in  case  of  hypertrophy  of  the  spleen  is  capable  of 
producing  anemia. 

The  pathologic  effects  of  the  action  of  such  poisons  upon  the  blood  and 
the  bone-marrow  are  shown,  in  part,  in  retrograde  changes — as  the  atrophy 
of  the  marrow  in  tuberculosis  and  chronic  nephritis,  in  part  by  chronic 
inflammatory  changes  and  by  progressive  nutritive  disorders,  by  way  of 
hypertrophies  and  new  tissue  formation  in  the  active  bone-marrow.  These 
new  growths  may  revert  in  type  to  the  most  primitive  marrow  germ  cells, 
which  are  really  in  the  nature  of  capillary  endothelium.  This  metaplastic 
formation  may  be  no  longer  confined  to  the  bone,  but  may  appear  in  widely 
diverse  parts  of  the  body.  It  is  most  common  in  the  liver,  spleen,  and 
lymph  nodes.  The  stimulation  of  these  reserves  may  repair  the  blood 
injury.  This  is  certainly  true  in  the  most  common  forms. 

1.  The  ordinary  mild  type  of  chronic  toxogenous  anemia  includes  the 
so-called  secondary  or  complicating  anemias  accompanying  tuberculosis, 
lues,  and  the  chronic  nephroses. 

The  clinical  picture  consists  essentially  of  the  symptoms  recited  and  of 
those  of  anemia  in  general,  described  under  chlorosis  and  post-hemorrhagic 
anemia. 

The  prognosis  and  course  depend  upon  the  extent  of  the  injury  done  by 
the  toxic  agent  and  upon  its  recognition,  avoidance,  and  removal. 

The  pathologic  effects  of  the  action  of  such  poisons  upon  the  blood  and 
the  bone-marrow  are  shown,  in  part,  in  retrograde  changes,  precisely  as  the 
appearance  of  diffuse  metaplastic  foci  of  blood-forming  parenchyma, 
already  described,  resembles  the  embryonic  hematopoiesis. 

2.  Biermer  or  pernicious  type  of  anemia  is  recognized  clinically  by  the 
appearance  of  large  numbers  of  megalocytes  and  megaloblasts.    At  times, 
these  giant  erythrocytes  are  so  numerous  that  the  reduced  hemoglobin 


168  TEXT-BOOK  OF  PEDIATRICS 

content  of  the  ordinary  red  cells  is  over-compensated  and  the  color  index 
runs  higher  than  one. 

The  exhaustion  of  the  myeloid  parenchyma  may  be  recognized  by 
leucopenia,  that  is  by  polynuclear  leucopenia,  relative  lymphocytosis, 
extreme  oligochromemia  and  oligocytosis,  poikilocytosis,  anisocytosis  and  a 
reduction  of  the  protein  content  of  the  blood-serum  which  is  of  a  deep  yellow 
color.  The  marked  loss  of  coagulability  which  underlies  a  hemorrhagic 
diathesis,  indicated  by  hemorrhages  of  the  mucous  membranes,  skin,  and 
retina,  is  a  fact  of  great  importance. 

Another  condition  very  rare  during  childhood  and  because  of  that 
probably  often  overlooked  is  the: 

3.  A  regenerative  (or  aplastic)  type  of  severe  anemia.     This  type  of 
anemia  may  occur  in  children  of  school  age,  rarely  before  and  pursues  a 
progressive  and  rapidly  fatal  course  extending  only  over  a  period  of  a  few 
months.    There  is  a  very  definite  hemorrhagic  diathesis  but  usually  little 
impairment  of  the  nutrition.    While  the  clinical  picture  resembles  that  of 
pernicious  anemia,  the  blood  picture  is  entirely  different.    There  is  a  com- 
plete and  constant  absence  of  all  signs  of  blood  regeneration  such  as  erythro- 
blastosis,  megalocytosis,  anisocytosis  and  polychoromatophilia  in  spite  of  a 
profound  reduction  in  the  hemoglobin  and  the  number  of  erythrocytes  and 
platelets.    Furthermore,  there  are  no  findings  on  examination  of  the  liver, 
spleen  and  lymph  nodes,  and  the  urine  is  normal. 

From  the  rarity  of  the  pernicious  type  of  anemia  in  childhood  and  from 
certain  peculiarities  of  this  disease,  such  as  enlargement  of  the  spleen  in 
younger  individuals,  it  may  be  inferred  that  the  blood  and  the  bone-marrow 
of  small  children  react  differently  from  those  of  the  adult  to  these  poisons. 
This  fact  has  been  determined  by  the  experiments  of  Reckzeh  and  others, 
and  by  observation  of  members  of  the  same  family  with  xeference  to  the 
effects  of  essentially  similar  blood  injuries  in  individuals  of  different  ages. 

4.  The  v.  Jaksch-Hayem  form  of  disease,  which  is  closely  related  to  the 
leucanemic  type,  seems  to  be  a  more  frequent  form  of  reaction  in  the 
youthful  organism. 

V.  Jaksch  and  Hayem  contemporaneously  described,  clinically,  this 
fairly  definite  form  of  disease,  occuring  quite  frequently  in  children  of  one- 
half  to  two  years,  under  the  name  of  pseudoleucemic  infantile  anemia. 
It  resembles  Biermer's  anemia  in  that  it  also  presents  evidence  of  intense 
stimulation  of  the  blood-forming  organs,  associated  with  the  signs  of  a 
breaking  down  of  the  blood-cells  and  hemosiderosis.  As  in  Biermer's 
anemia,  too,  the  stimulation  leads  to  the  extension  of  the  erythroplastic 
parenchyma  of  the  bone-marrow  to  new  formations  of  intra-  and  extra- 
vascular  hemopoietic  foci  in  the  liver,  spleen,  lymph  nodes,  and  kidneys. 
Qualitative  reversion  of  erythropoiesis  to  the  embryonic  type  also  occurs. 
It  differs  from  the  pernicious  form,  however,  in  the  fact  that  the  myeloid 
foci  in  the  liver,  and  more  particularly  in  the  spleen,  develop  to  so  great  an 
extent  that  the  size  of  these  organs  is  largely  increased  and  an  intensive 
leucopoietic  activity,  marked  by  added  numbers  of  white  cells  in  circula- 
tion, takes  place. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS 


169 


The  Symptoms  may  be  anticipated  from  the  foregoing  description  The 
examination  of  the  blood  usually  shows  oligocytosis,  with  from  one  to  three 
million  red  cells,  and  oligochromemia.  The  reduction  of  the  hemoglobin  may 
be  proportionately  in  excess  of  the  diminution  of  the  number  of  the  red  cells 
— a  normocytotic  regenerative  type  with  reduced  color  index — or  it  may  be 
relatively  less.  The  latter  condition  obtains  when  the  regeneration  of 
megalocytes  is  a  prominent  feature ;  that  is,  when  these  and  the  megaloblasts 
appear  in  the  circulation,  the  color  index  often  ranging  to  one  hundred  or 
more.  Poikilocytosis,  polychromasia,  basophilic  granulation,  and  indica- 
tions of  the  breaking  down  of  cell  nucleii  are  characteristic.  An  associated 


FIG.  34. — Sixteen-month-old  boy  and  fourteen-montri- 
old  girl  with  rickets  and  Jakach's  anemia.  Both  children 
recovered  after  several  weeks  of  treatment. 

leucocytosis  of  varying  degree  and  type  may,  or  may  not,  be  present.  The 
number  of  leucocytes  is  supposedly  indicative  of  the  severity  of  the  disease 
and  is  usually  about  20,000.  At  times  and  particularly  in  inflammatory  con- 
ditions the  granular  forms  predominate,  but  usually  the  non-granular  are  the 
more  numerous.  The  eosinophilic  cells  and  sometimes  the  myelocytes  are 
increased.  In  some  cases  the  large  number  of  mononuclear  cells,  running  up 
to  twenty  per  cent,  is  a  very  noticeable  feature. 

The  rest  of  the  clinical  picture  of  the  disease  is  that  of  rickets  accompa- 
nying the  high  grade  anemia.  A  dull  yellow  pallor,  a  general  listlessness, 
and  a  wilted  appearance  are  very  apparent.  The  persistence  of  a  certain 
amount  of  cutaneous  adipose  tissue  gives  a  pasty  look.  Numerous  .small 
hemorrhages  into  the  skin  and  mucous  membranes  occur.  The  enlarged 
spleen,  hard  and  with  a  sharp  edge,  but  not  tender,  always  extends  below 


170  TEXT-BOOK  OF  PEDIATRICS 

the  costal  margin  and  may  frequently  reach  to  the  level  of  the  umbilicus  or 
even  lower,  greatly  distending  the  abdominal  wall.  There  is  marked  swell- 
ing of  the  liver,  which  is  soft  and  also  has  a  sharp,  thin  edge.  There  is  slight 
enlargement  of  all  the  lymph  nodes.  Accidental  heart  murmurs  are  rare. 
The  pulse  is  full  and  soft. 

Occurrence,  Course  and  Prognosis. — Jaksch-Hayem 's  anemia  begins 
between  the  seventh  and  the  sixteenth  months  of  life.  It  is  almost  entirely 
confined  to  artificially-fed  children  and  especially  to  those  of  the  poorer 
districts  of  large  cities.  Gradually,  and  at  times  rapidly,  it  reaches  a  severe 
degree.  It  persists  for  months,  but  rarely  until  the  third  year  or  later, 
after  which  spontaneous  recovery  takes  place  in  a  certain  per  cent,  of  cases. 
No  other  form  of  anemia  which,  judging  by  the  general  symptoms  and  the 
blood  picture,  is  equally  severe  offers  so  good  chances  of  favorable  termi- 
nation. Rickets  is  responsible  for  most  of  its  fatal  complications,  in  the  form 
of  intestinal  disturbance,  broncho-pneumonia,  and  muscular  degenerations. 
Hydrops  and  hemorrhages  occur  but  rarely. 

Etiology. — From  the  clinical  viewpoint,  tuberculosis,  syphilis,  typhus, 
other  infectious  diseases,  intestinal  parasites,  chronic  disturbances  of  nutri- 
tion, and  poisoning  are  occasionally  given  as  etiologic  factors;  but  rickets 
evidently  stands  in  much  closer  relationship  to  Jaksch-Hayem 's  anemia 
than  any  of  these.  Since  rickitic  skeletal  changes  may  be  demonstrated  at 
autopsy  in  almost  every  child  of  this  age  who  succumbs  (see  page  196),  the 
combination  of  this  disease  with  pseudoleucemic  anemia  is  not  necessarily 
astonishing.  So  associated,  rickets  commonly  attains  at  least  a  medium 
intensity  and  usually  a  severe  degree.  It  remains  clinically  manifest  and 
florid  until  the  second  or  third  year. 

Recently  Aschenheim  and  Benjamin,  as  well  as  Marfan,  have  attempted 
to  clear  up  the  relationship  between  the  two  diseases. 

While  these  views  are  very  worthy  of  consideration,  the  writer  can  not 
commit  himself  to  them  without  reserve  so  long  as  the  knowledge  of  the 
etiology  of  rickets  itself  is  no  further  advanced.  For  the  present  Naegeli's 
view  must  suffice  for  the  systematic  classification  of  Jaksch's  anemia.  Ac- 
cording to  this  view,  the  disease  represents  a  variety  of  secondary  anemia 
arising  from  peculiar  biologic  conditions  in  the  early  stages  of  infantile 
development.  The  primary  causes  are  found  in  repeated  infections  and 
faulty  nutrition  during  the  first  years  of  life.  On  the  one  hand,  it  appears 
that  rickets  may  arise  as  a  sequel  of  these  injuries  and,  on  the  other  hand, 
Jaksch's  anemia  may  result  from  them  in  that  critical  and  important  period 
of  development,  at  the  close  of  the  first  year,  when  there  is  a  tendency  to 
germinal  disease. 

5.  The  "Alimentary  Anemia"  of  Czerny. — As  previously  indicated, 
Czerny  believes  that  in  certain  constitutionally  predisposed  individuals  an 
abnormal  metabolism  results  in  the  elaboration  of  acid  products  from  milk 
(also  from  starches)  which  are  toxic  to  the  blood-forming  parenchyma. 

To  distinguish  it  from  the  ordinary  form  of  alimentary  anemia  pre- 
viously described  and  which  results  from  a  deficiency  in  blood-building 
material,  the  term  trophotoxic  anemia  would  probably  be  preferable.  The 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  171 

clinical  picture  of  this  form  of  anemia  as  given  by  Kleinschmidt  is  so  vari- 
able as  to  make  a  description  of  the  condition  difficult.  Some  of  the  chil- 
dren were  thin,  others  fat,  some  had  a  yellowish  coloration  of  the  skin, 
others  were  very  white,  some  had  small,  others  large  hemorrhages  into  the 
skin.  Edema  was  occasionally  encountered.  Enlargement  of  the  liver  and 
spleen  was  often  noted,  though  there  was  only  slight  enlargement  of  the 
lymph  nodes.  A  reduction  in  the  hemoglobin,  usually  30-45  per  cent,  and  a 
less  marked  oligocytosis  were  the  only  constant  blood  findings.  In  contrast 
to  these  mild  pseudochlorotic  cases  were  the  more  severe  ones  with  oligo- 
cytosis, poikilocytosis,  polychromatophilia  and  erythroblastosis.  There 
was  usually  a  lymphocytic  leucocytosis  of  15-18,000.  Evidences  of  a 
marked  activity  of  the  bone-marrow,  occasionally  hemosiderosis,  and  a 
fatty  degeneration  of  the  heart  were  the  pathological  findings. 

The  sole  criterion  for  the  nosological  identity  and  the  alimentary  origin 
of  this  protean  condition  is  the  favorable  reaction  to  dietary  measures. 
Whatever  benefit  is  obtained  from  this  must,  however,  be  an  indirect  one, 
as  the  same  diet  is  employed  in  those  constitutional  disorders  most  often 
associated  with  alimentary  anemia.  (Rickets,  exudative  diathesis,  lym- 
phatism  and  "milchnahrschaden".)  Czerny's  alimentary  anemia  espe- 
cially in  its  more  severe  form  may  be  included  in  v.  Jaksch-Hayem's  anemia 
which  is  better  defined.  To  discard  the  latter  and  substitute  the  former, 
as  some  desire,  would  not  be  advisable  at  least  so  long  as  the  origin  of  ali- 
mentary anemia  is  hypothetical. 

6.  A  group  of  rare  diseases  in  which  the  erythropoietic  system  is  chiefly 
affected,  caused  also  by  toxogenous  injuries,  operating  even  in  the  embryo, 
is  observed  in  childhood.  Symptomatically,  at  least,  the  diseases  of  this 
group  are  closely  related,  as  is  shown  by  the  following  common  changes 
which  include  the  general  manifestations  of  anemia,  oligocytosis,  or  more 
rarely  polycytosis,  oligochromemia,  embryonic  erythropoiesis,  with  the 
occurrence  of  megaloblasts.  They  present,  also,  an  increased  destruction  of 
red  blood-cells,  with  its  consequences  in  hemosiderosis,  pigmentation  of  the 
skin,  enlargement  of  the  liver,  jaundice,  the  excretion  of  bilirubin,  urobilin 
and  urobilinogen;  early  spodogenous  enlargement  of  the  spleen,  and  varia- 
tions in  the  leucocyte  count,  as  in  Jaksch'  anemia.  Leucopenia,  relative 
lymphocytosis,  and  finally  a  hemorrhagic  diathesis  may  be  found. 

One  of  the  types  included  in  this  group,  described  as  chronic  familial 
hemolytic  icterus,  suggests  the  characteristics  of  paroxysmal  hemoglobi- 
nuria  on  account  of  its  familial  and  early  appearance,  the  demonstrable 
reduction  of  the  resistance  of  the  red  blood-cells,  which  are  broken  down 
particularly  after  exposure  to  cold,  its  paroxysmal  character,  and  its  favor- 
able course;  and,  finally,  its  relationship  to  lues  and  other  toxic  infections. 
Autolytic  hemolyses,  however,  have  not  been  found  in  this  condition. 

The  cases  belonging  to  the  Banti-Senator  symptom-complex  appear  at 
a  later  period  of  life,  and  usually  after  the  fifth  year.  They  follow  a  chronic 
course  and  terminate  fatally  in  spite  of  treatment.  Ascites,  icterus,  enlarge- 
ment, followed  by  contraction,  of  the  liver,  commonly  appear  late.  In  the 
final  stages  of  the  disease  fibrosis,  an  enormous  spleen,  and  cirrhosis  of  the 


172  TEXT-BOOK  OF  PEDIATRICS 

liver  are  found.  The  author  has  never  seen  an  actual  case  of  Banti  's  Disease 
going  on  to  recovery,  with  a  negative  nitrogen  balance,  after  the  operative 
removal  of  the  spleen  as  the  primary  seat  of  the  disease.  Nor  has  he  been 
able  to  establish,  in  the  cases  which  havo  come  under  his  observation,  the 
alleged  fact  that  this  symptom-complex  always  belongs  to  late  syphilis. 
A  very  significant  sign  of  disease  in  these  cases,  and  often  the  first  to  be 
noted,  is  a  profuse,  repeated,  and  even  fatal  hemorrhage  from  the  gastro- 
intestinal tract,  \\fhen  in  doubt  this  condition  should  be  treated  specifically. 

In  Gaucher's  splenomegaly  the  early  enlargement  of  the  spleen  to 
enormous  size  is  the  most  important  feature.  Its  course  is  similar  to  that  of 
Banti 's  Disease  and  it  is  looked  upon  as  a  peculiar  disease  of  the  lympho- 
erythropoietic  system. 

Attention  should  be  called  to  the  curative  effect  of  splenectomy  in  the 
last  two  types. 

THE  TREATMENT  OF  ANEMIA 

In  those  forms  of  toxic  anemia  in  which  the  poison  is  known  and  its 
source  recognized,  a  successful  therapy  aims  at  the  removal  of  the  cause. 
Examples  are  found  in  parasitic  or  luetic  anemias. 

The  therapy  is  quite  clear  in  those  cases  in  which  there  is  a  deficiency  of 
certain  hygienic  factors.  Exercise  in  the  open  air,  stimulation  of  the  skin, 
the  influence  of  sunlight,  etc.,  are  indicated.  Treatment  is  self-evident 
when  there  is  an  actual  poverty  of  iron  in  the  food.  This,  as  already  sug- 
gested, is  a  very  rare  condition  and  the  iron  supply  required  should  be 
prescribed  from  the  garden  and  not  from  the  pharmacy.  The  natural 
combinations  of  iron  in  food-stuffs  are  absorbed  more  completely  and  in 
more  acceptable  form  than  is  the  iron  of  the  customary  preparations 
(Krasnogorski).  Most  of  the  green  vegetables,  cereals,  legumes,  potatoes 
and  fruits  have  sufficient  iron  content;  they  are  taken  without  objection  and 
are  comparatively  cheap.  It  is  not  necessary  to  be  guided  by  tables  as  to 
their  iron  content,  since  an  excess  of  iron  is  readily  obtainable.  If  the 
child  refuses  vegetables  it  is  either  a  question  of  serious  defect  in  training  or 
of  overfeeding  with  eggs  and  milk.  In  that  event  the  quantity  of  these 
items  may  be  reduced,  or  they  may  be  entirely  eliminated  from  the  menu  in 
order  to  force  the  child  to  accept  vegetables.  Both  milk  and  eggs  may  be 
readily  dispensed  with  during  the  second  year  and  may  be  omitted,  if 
necessary,  at  the  end  of  the  first  year.  They  would  appear  to  have  an 
unfavorable  influence  upon  the  results  of  a  vegetable  diet.  When  carefully 
prepared,  mashed  vegetables,  especially  spinach  and  carrots  cooked  in  their 
own  juices,  are  usually  borne  very  well  at  this  age.  The  appearance  of 
green  or  red  stools,  containing  undigested  particles  of  these  vegetables,  is 
no  contraindication. 

The  diet  prescribed  by  Czerny  in  alimentary  anemia  is  as  follows: — 

First  Meal. — 100  c.c.  milk  diluted  with  an  equal  amount  of  cereal  water, 
a  little  softened  zwiebach  or  bread  with  a  little  butter  or  preferably 
marmalade. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  173 

Second  Meal. — Fresh  fruit  with  biscuits,  zwiebach  or  a  little  bread 
and  butter. 

Third  Meal. — Broth  thickened  with  cereals,  rice,  oat  or  potato  gruel. 
In  addition  puree  of  vegetables,  meat,  also  liver  (minced,  1-2  teaspoonfuls). 

Fourth  Meal. — The  same  as  No.  3,  or  in  the  case  of  older  children,  bread 
and  butter  with  meat  or  sausage  and  fruit  in  addition. 

It  may  be  possible  in  the  anergic-aplastic  and  trophotoxic  foims  of 
anemia  to  stimulate  the  hemopoietic  function,  and  especially  a  new  forma- 
tion of  hemoglobin  in  unknown  foci,  by  means  of  artificial  stimulating 
substances.  Such  a  stimulating  property  has  been  ascribed  to  iron.  It 
cannot  be  tested  by  animal  experiments  because  these  foims  of  anemia 
cannot  be  produced  artificially.  Experiences  gained  at  the  bedside,  showing 
that  medicinal  iron  may  be  depended  upon  to  a  certain  extent  in  diseases 
coming  under  the  group  of  chlorosis,  and  probably  as  well  in  chronic  post- 
hemorrhagic,  anemias,3  which  are  in  some  respects  similar,  would  seem  to 
indicate  that  the  action  of  iron  is  related  to  these  especial  conditions. 

For  chlorosis,  iron  is  prescribed  in  the  form  of  pillulse  ferri  carbonatis 
(Blaud's  pills)  1  to  3  after  each  meal.  In  Czerny's  anemia  Feer,  contrary 
to  the  views  of  the  former,  recommends  ferrum  reductum  (0.05-0.1  gram, 
2  to  3  times  daily)  in  addition  to  a  limitation  of  the  amount  of  milk.  Of 
numerous  other  preparations  including  the  ferruginous  mineral  waters  none 
are  as  useful  as  Blaud  's  pills.  Proprietary  synthetic  preparations  of  organic 
iron  and  the  wines  and  liquors  are,  to  put  it  mildly,  not  indispensable. 
Because  of  their  low  iron  content  very  large  doses  would  be  required  to 
obtain  the  same  effect.  When  assimulation  is  sought,  the  natural  foods 
suffice,  and  the  so-called  stimulating  effects  are  obtained  from  the  simple 
and  inexpensive  preparations  of  inorganic  iron. 

Another  method  of  treatment  is  to  take  advantage  of  the  adequate 
natural  erythropoietic  stimulation.  These  natural  stimuli  are  loss  of  blood 
and  increased  destruction  of  red  blood-cells.  The  former  is  secured  by 
blood-letting;  the  latter  usually  by  the  use  of  arsenic  in  Fowler's  solution 
(liquor  potassii  arsenitis)'.  Arsenic  is  also  supposed  to  cause  an  increased 
output  of  erythrocytes  into  the  circulation  from  the  reservoirs  of  the  bone- 
marrow.  In  pernicious  anemia  in  the  adult,  arsenical  therapy  has  been 
justified  in  a  purely  empirical  way.  In  v.  Jaksch's  anemia,  occurring  in 
weak  children  during  the  first  year  or  so,  this  form  of  treatment  is  hardly 
ever  indicated.  However,  Fowler's  solution,  diluted,  in  divided  doses  of 
from  2  to  12  drops  daily,  may  be  tried.  It  is  very  important  to  treat  the 
rickets  if  there  is  any  present. 

Attempts  at  organotherapy  in  anemia  rest  upon  the  theory  of  a  hor- 
mone stimulation  of  the  blood-forming  parenchyma.  Huebner  feeds  small 
amounts  of  fresh  bone-marrow  with  bread  and  butter.  It  should  be  quite 
unnecessary  to  say  that  from  active  red  marrow  alone,  may  results  be  ex- 
pected, and  not  from  the  ordinary  fat  marrow.  Freshly  expressed  meat 
juice  given  in  spoonful  quantities  is  to  be  recommended.  The  transfusion  of 

3  A  single  loss  of  blood  in  itself  acts  as  a  sufficient  stimulus  to  erythropoiesis.  The 
circulatory  system  may  be  more  rapidly  filled  by  the  addition  of  water  in  various  ways. 


174  TEXT-BOOK  OF  PEDIATRICS 

blood,  which  has  been  mentioned  again  lately,  has  an  organotherapeutic 
effect  beyond  that  of  merely  compensating  blood  loss.  In  post-hemorrhagic 
anemia,  3  to  5  intramuscular  injections  of  15-20  c.c.  of  fresh  human  blood 
at  intervals  of  several  days  may  be  given,  as  well  as  injections  of  normal 
saline.  Autotransfusion  by  the  use  of  tight  bandages  may  also  be  employed. 

The  treatment  of  chlorosis  and  secondary  anemias  by  "physical," 
meaning  by  this  hydrotherapeutic  measures,  is  the  vogue  in  private  hospi- 
tals and  sanatoriums.  In  the  case  of  chlorosis,  depletive  sweat  baths  (a  hot 
bath  followed  by  a  hot  pack  every  five  days)  are  possibly  of  value.  Even 
here,  one  recommends  cold  sponges,  cold  rubs  and  even  cold  baths  and 
douches,  the  other  hot  applications  and  hot  water  and  hot  air  baths.  Such 
differences  of  opinion  do  not  awaken  special  confidence.  Probably,  the 
stimulation  of  the  skin  is  the  important  feature,  and  if  this  is  true,  the 
method  of  producing  it  is  of  minor  importance.  In  the  enthusiasm  over 
artificial  sunlight,  the  beneficial  effects  of  natural  sunlight  are  apt  to  be 
overlooked.  (Sun-baths  on  warm,  quiet  days,  one-half  to  one  hour  twice 
daily,  at  first  only  the  limbs,  later  the  trunk  followed  by  cool,  wet  rubs  are  to 
be  recommended.)  The  value  of  high  altitude  lies  in  the  therapeutic  appli- 
cation of  oxygen-poor  air  (David). 

For  older  children  the  most  effective  measure  is  a  visit  to  the  country, 
with  suitable  outdoor  or  fresh  air  camp  life  at  an  altitude  of  1500  to  4500 
feet,  the  elevation  to  be  governed  by  the  child's  condition  and  by  the 
altitude  at  which  he  has  been  accustomed  to  live.  A  sojourn  in  such  a  place 
gives  opportunity  of  recreation  and  of  intelligent  and  instructive  physical 
exercise  in  the  open.  Climates  which  experience  shows  to  have  a  bad  effect 
should  be  avoided.  Tedious  walks  on  the  sanatorium  promenade  and  the 
constant  contact  with  convalescents  should  be  avoided.  When  a  southern 
sea-shore  resort  is  chosen,  the  baths  should  be  carefully  watched.  In  some 
instances,  it  will  be  necessary  to  keep  the  child  out  of  school  for  a  long  time, 
or  at  least  to  eliminate  the  less  essential  studies.  Fresh  air  cures  of  a  less 
intense  nature  than  those  carried  out  in  the  mountains  and  on  the  seacoast 
can  be  pursued  at  home,  and  with  certain  precautions  in  the  large  cities  of 
the  north  and  south.  Sleeping  in  the  open  with  ample  protection  should 
be  tried. 

Changes  in  the  spleen  noted  by  Banti  in  the  syndrome  bearing  his  name 
and  by  Eppinger  in  the  Biermer  type  of  pernicious  anemia  raises  the  ques- 
tion of  the  value  of  splenectomy  in  these  and  related  conditions.  Even 
though  these  changes  may  not  be  causal  (as  some  believe),  nevertheless, 
the  value  of  this  procedure  is  borne  out  by  clinical  experience.  Whether 
exposure  to  the  Roentgen  rays  can  be  effectively  substituted  for  this  oper- 
ation is  still  questionable. 

APPENDIX 
PSEUDO-ANEMIAS 

In  many  children,  superficially  adjudged  to  be  anemic,  or  thin-blooded, 
either  by  the  laity  or  by  physicians,  other  conditions  present  themselves 
which  warrant  description  in  this  connection,  even  though  they  are  properly 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  175 

classified  elsewhere.  If  pallid  infants  or  older  children  be  examined  indis- 
criminately their  hemoglobin  index  and  their  red  cell  count  will  be  found,  in 
the  major  number,  within  physiologic  limits.  These  children  are  either  not 
in  any  degree  anemic,  or  are  really  oligemic,  that  is,  the  vascular  system 
contains  a  diminished  quantity  of  a  blood  which  has  a  normal  pigment  con- 
tent and  a  normal  cell  content.  Until  recently  it  has  been  impossible  to 
determine  which  of  these  two  conditions  is  really  present,  since  the  oppor- 
tunity of  autopsy  is  rare  and  since  the  technical  difficulties  which  surround 
the  in  vivo  determination  of  the  quantity  of  blood  are  great.  However, 
the  gap  has  been  bridged  by  Erich  Mueller.  By  the  methods  of  Zuntz  and 
Plesch  it  has  been  found  possible  to  determine  the  total  volume  of  blood,  the 
total  hemoglobin  content,  and  the  oxygen  capacity  of  the  blood  of  pale 
children  over  six  years  of  age.  Children  with  chronic  nephritis  or  tubercu- 
losis, and  those  living  under  especially  unfavorable  hygienic  conditions, 
were  excluded  from  these  studies.  No  differences  were  found  in  these 
pallid  children  as  compared  with  healthy-looking  specimens.  In  such  cases, 
therefore,  one  has  to  deal,  not  with  an  oligemia,  but  with  a  pseudo-anemia. 
The  existence  of  such  conditions  has  been  suspected  for  some  time  (Sahli, 
Strauss  and  others).  A  reduced  transparency  of  the  epidermis  or  a  lessened 
fulness  of  the  skin  capillaries  have  been  considered  as  causes  of  the  con- 
dition. The  ischemia  may  be  due  to  a  decreased  development  of  the  capillary- 
net- work  of  the  skin,  or  to  a  dilatation  of  the  blood-vessels  of  other  organs, 
or  to  a  contraction  of  the  skin  vessels — a  cuticular  angiospasm.  The  last 
two  of  these  factors  are  especially  associated  in  the  occurrence  of  the  marked 
color  changes  to  which  such  children  are  liable. 

Plumbism  and  chronic  nephroses,  usually  responsible  for  the  pseudo- 
anemia  of  adults,  can  be  considered  in  only  a  small  percentage  of  cases  in 
childhood.  An  association  of  phenomena  suggests  a  consideration  of  cause 
in  still  another  direction.  A  group  of  sickly  children,  the  subjects  of  hered- 
itary taint  and  of  errors  in  physical  development,  with  a  marked  tendency 
to  the  lymphatic  diathesis,  includes  many  of  these  infantile  pseudo-anemias. 
Psychic  traumata  of  various  types,  for  example,  states  of  fear  and  depression 
associated  with  school  duties  or  unpleasant  home  conditions  play  a  great 
role.  It  is  obvious  that  a  correction  of  these  conditions  rather  than  iron, 
arsenic  and  the  other  forms  of  treatment  so  often  employed,  are  to  be  rec- 
ommended. A  careful  analysis  by  the  family  physician  of  these  conditions 
as  well  as  the  intelligent  cooperation  of  the  parents  are  necessary,  all  of 
which  of  course  requires  greater  effort  than  the  mere  feeding  of  pills. 

B.  GROUP  OF  LEUCEMIAS  AND  PSEUDOLEUCEMIAS 

Pathologic  research  is  sufficiently  advanced  to  offer  a  reliable  basis  for  the 
scientific  classification  of  this  group.  The  confusion  into  which  the  purely 
hematologic  study  of  the  group  has  been  thrown  by  the  variety  of  clinical 
findings,  particularly  as  to  relations  between  true  and  pseudo-leucemias,  has 
been  composed  by  pathologic  researches  alone.  In  a  degree,  the  clinical  pic- 
ture worked  out  at  the  bedside  still  fails  of  likeness  to  the  features  which 
the  autopsy  presents  and  fuller  conformity  must  be  left  to  the  clinician. 


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The  several  forms  of  disease  included  in  this  group  are  due  to  marked 
and  more  or  less  widely  disseminated  changes  in  the  lymphoid  or,  the 
myeloid  system  and,  taken  in  their  entirety,  may  be  likened  to  a  progres- 
sive disturbance  of  nutrition.  The  following  scheme  will  serve  the  purpose 
of  eliminating  a  didactic  presentation  and  will  suggest  the  great  impetus 
which  an  effective  clinical  terminology  gives  toward  the  association  of 
heterogeneous  conditions  and  the  differentiation  of  homogeneous  types. 


Structural 

Affections  of  the 

Affections  of  the 

Clinical 

Basis. 

Lymphoid  System. 

Myeloid  System. 

Terminology. 

(Lymphadenoses.) 

(Myeloses.) 

General  hyper- 
plasia  with  ex- 

1. Lympho- 
cytomatosis. 

3.  Myelocy- 
tomatoses. 

With  in-           f  Lymphatic 
crease  of           1  and  myeloid 

pansive,  but 

cells  in  the       ]  leucemia  and 

not  aggressive 

blood  stream.  [  chloroma. 

growth. 

Without 

True  pseudo- 

increase  of 

leucemia 

cells  in  the 

(Pinkus- 

bloodstream. 

Cohnheim). 

Hyperplasia 
with  aggressive 

2.  Lympho- 
sarcomatoses 

4.  Myelo- 
sarcomatoses. 

Lympho- 
•  and  myelo- 

Pseudo- 
•  leu- 

tumor-like 

(Kundrat.) 

sarcomata. 

cemia. 

growth,  and 

atypical 

proliferation. 

Pseudo-hy- 

5.  Granulo- 

Steinberg's 

perplasia; 

matoses. 

disease. 

metaplastic 

proliferation, 

especially  in 

the  connective 

tissue  cells  of 

the  stroma. 

Distinctly  localized  leucemic  and  pseudoleucemic  affections,  that  is  the  local 
lympho-  and  myelosarcoma  of  a  particular  organ,  which  have  the  distinct  characteristics 
of  a  malignant  tumor,  and  solitary  granuloma  are  not  included  in  this  classification 
of  more  or  less  generalized  diseases. 

1.  LYMPHOCYTOMATOSES 

This  group  of  leucemias  presents,  from  the  outset,  generalized  systemic 
disease  conditions  of  all  the  lymphoid  tissues.  The  lesions  consist  in  the 
proliferation  of  preformed  lymphatic  tissue  and  in  the  adventitious  growth 
of  similar  new  tissue  in  the  several  organs. 

Since  under  these  conditions  the  elements  of  the  non-granular  system  of 
blood-cells  appear  in  the  blood  in  increased  number,  these  disorders  have 
been  designated  as: 

LEUCEMIC  LYMPHADENOSIS  OR  LYMPHATIC  LEUCEMIA 

In  lymphatic  leucemia  the  parenchyma  of  the  lymph  nodes,  the  spleen, 
the  tonsils,  the  lymph  follicles  of  the  tongue,  and  of  small,  disseminated 
masses  of  lymphoid  tissue  in  other  organs,  as  the  thymus,  bone-marrow  and 
kidneys,  is  increased  to  a  varying  and  often  irregular  extent  by  a  process 
of  atypical  proliferation.  Surrounding  the  blood-vessels  widespread, 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS 


177 


semicircular,  and  newly  formed  adventitious  collections  of  lymphocytes  are 
found.  Usually  the  proliferation  results  in  an  enlargement  of  the  affected 
organ  which  may  reach  a  marked  degree,  with  consequent  obliteration  of 
the  normal  architectural  lines.  Abnormal  forms  of  cells,  probably  of  an 
embryonal  type,  consisting  of  large  mononuclears,  atypical  lymphocytes  and 
"Rieder  V  cells,  appear.  The  infiltration  of  the  surrounding  parts  often 
suggests  malignancy;  but  the  elements  of  neighboring  tissues  do  not  actually 
contain  new  cells,  although  they  may  be  choked  by  their  expansive  growth. 


FIG.   35. — Eight-year-old  boy   with    acute   lymphatic    leucemia, 
showing  swelling  oi  lachrymal  glands. 

Onset,  Course  and  Symptoms. — The  course  of  lymphatic  leucemia,  to 
which  childhood  shows  a  special  predisposition  is  almost  always  acute,  that 
is,  it  has  a  duration  of  several  weeks,  averaging  about  two  months.  It  is 
always  fatal.  The  new-born  and  young  infants  are  similarly  affected.  The 
clinical  picture  resembles  that  of  a  sudden  infection,  with  the  prodromes  of 
anemia.  Its  general  symptoms  are  those  of  high  fever,  languor,  headache, 
dizziness,  pain  in  the  extremities  referred  to  the  bones,  numbness,  vomiting, 
diarrhoea,  and  later,  edema.  Indications  of  a  hemorrhagic  diathesis  appear 
in  the  form  of  petechise  of  the  skin  and  mucous  membranes,  and  of  foul, 
12 


178  TEXT-BOOK  OF  PEDIATRICS 

ichorous  ulcers  resulting  in  the  breaking  down  of  lymphomata.  Hyper- 
plasia  of  the  tonsils  and  a  variable  degree  of  swelling  of  the  lymph  nodes  at 
the  angle  of  the  jaw,  in  the  neck,  and,  more  rarely,  in  the  groin  occur.  The 
thymus,  liv^r,  and  spleen  are  enlarged  and  hard.  Albuminuria  and  casts 
are  common,  together  with  an  increase  of  the  endogenous  purin  bases  and 
the  phosphates,  due  probably  to  the  breaking  down  of  cell  nuclei.  In 
advanced  stages  the  clinical  picture  is  further  complicated  by  inflammation 
of  the  serous  membranes.  Leucemic  infiltrations  in  the  skin,  mesentery, 
salivary  and  lachrymal  glands,  etc.,  are  of  less  frequent  occurrence. 

The  diagnosis  is  established  by  the  typical  blood  findings.  These  consist 
in  the  light  color  of  the  blood,  its  slow  coagulation,  the  moderate  to  high 
grade  increase,  both  absolute  and  relative,  of  the  non-granular  leucocytes, 
among  which  are  found  undeveloped  and  atypical  forms,  and,  in  particular 
large  lymphocytes  and  weakly  staining  polymorphonuclear  cells  (Rieder's), 
in  excess.  Large  numbers  of  lymphocytes  of  normal  size  are  found  less 
commonly.  An  absolute  and  relative  reduction  in  the  number  of  cells 
which  have  their  origin  in  the  myeloid  parenchyma  is  indicative  of  changes 
in  the  bone-marrow  and  may  resemble  the  findings  in  severe  toxic  anemia, 
in  the  way  of  oligocytosis,  poikilocytosis,  anisocytosis,  basophilic  granu- 
lation, normoblasts,  megaloblasts  and  myelocytes.  If  the  lymph  anemia  ie 
retarded  because  of  the  not  infrequent  occurrence  of  septic  infection  the 
condition  may  be  mistaken  for  so-called  glandular  fever,  for  hypertoxic 
diphtheria  with  psuedomembranous  deposits  in  the  mucous  membranec,  or 
for  typhoid  fever.  A  leucemic  infiltration  which  is  said  to  cast  a  character- 
istic paravertebral  shadow,  lateral  to  the  descending  aorta,  has  been  noted 
in  Roentgenograms  by  Goett. 

For  reasons  yet  unknown,  the  numbers  of  lymphocytic  elements  in  the 
circulation  in  such  lymphadenoses  may  be  very  small.  They  may  appear 
only  in  the  later  stages  or  they  may  be  absent  throughout  the  entire  course. 

The  so-called  true  pseudoleucemias  (Cohnheim-Pinkus),  are  sub-  or 
aleucemic  lymphadenoses.  They  must  be  differentiated  from  Werlhof's 
disease,  from  fulminative  purpura,  and  sepsis.  The  more  chronic  and  afeb- 
rile  affection  is  quite  rare,  however,  in  childhood. 

Furthermore,  the  physiologic  lymphocytosis  of  early  childhood  may  be 
increased  to  such  an  extent  by  infectious  conditions  (typhoid,  pertussis, 
scarlet  fever,  syphilis),  or  by  the  common  inflammatory  diathesis,  as  to 
resemble  a  lymphemia  or  lymphadenosis. 

2.  LYMPHOSARCOMATOSES 

Lymphosarcomatoses  occur,  particularly,  in  young  individuals.  They 
resemble  malignant  tumors  in  that  their  origin  is  not  diffuse,  but  rather  a 
gradually  spreading  affection  of  the  lymphatic  system  of  aggressive  quality, 
with  the  formation  of  metastases.  They  represent  an  apparently  slow 
transitional  stage  from  the  lymphocytomatoses  (the  lymphatic  leucemia  and 
pseudoleucemia  of  Cohnheim-Pinkus),  to  the  true  lymphosarcomata. 

The  most  common  form  is  the  lymphosarcomatosis  arising  from  the 
mediastinum.  It  follows  a  chronic  course  and  produces  a  cachexia.  The 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS 


179 


mediastinal  lymph  nodes,  frequently  including  the  thymus,  enlarge  to  form 
a  densely  compacted  tumor  mass.  This  mass,  on  account  of  the  limited 
space  in  the  thorax,  soon  produces  the 
signs  and  symptoms  of  compression,  in 
the  way  of  dulness,  shadows,  pressure 
upon  blood-vessels,  nerves,  and  bron- 
chi; thromboses,  paralyses,  stenoses, 
compression  of  the  lung  apices  and  the 
pericardium.  Later,  other  groups  of 
lymph  nodes  lying  in  the  immediate 
neighborhood,  and  at  even  more  dis- 
tant points,  become  involved.  The 
spleen  and  the  liver  usually  remain 
unaffected,  both  clinically  and  anatom- 
ically. Toward  the  close  of  the  disease 
the  evidence  of  a  hemorrhagic  diathesis 
may  appear. 

The  blood  findings  may  be  fairly 
normal  for  a  long  while.  In  contrast  to 
the  findings  in  lymphocytomatoses,  the 
non-granular  cells  are  never  increased, 
but  rather  very  frequently  decreased. 
The  consequence  is  a  relative  granular 
leucocytosis  which  may  become  abso- 
lute in  consequence  of  the  formation  of 
metastases  in  the  bone-marrow.  In 
such  cases  the  development  of  anemia 
is  to  be  expected 

Lymphosarcomatosis  of  the  ab- 
dominal lymph  nodes  produces  similar 
manifestations. 


FIG.  36. — Six-year-old  boy  with  so-called 
pseudoleucemia  (Cohnheim-Pinkus).  Upon 
admission  the  blood  contains  5000  leucocytes, 
4.2  million  reds,  no  marked  oligochromemia, 
74  per  cent,  polynuclears,  18.5  per  cent,  large 
mononuclears  and  2.5  per  cent,  eosinophiles. 
The  swelling  of  the  lymph  nodes  had  persisted 
for  nine  months  and  had  caused  venous  con- 
gestion. Intrathoracic  lymph  tumors  com- 
pressed the  trachea.  Von  Pirquet  negative. 
The  tumors  began  to  disappear  when  the 
arsenic  treatment  was  instituted  and  contin- 
ued to  diminish  in  size  spontaneously. 


3.  THE  MYELO-CYTOMATOSES 

The  myelo-cytomatoses  are  systemic  diseases  of  the  myeloid  tissues  of 
the  body.  They  are  characterized  by  proliferation  and  increased  functional 
activity  of  the  preformed  myelotic  tissue  in  the  bone-marrow  and  by 
diffuse  adventitial  new  formations  of  such  tissue  in  the  various  organs. 
Besides  the  bone-marrow,  the  spleen,  the  lymph  nodes,  and  the  liver 
are  especially  affected  by  these  intumescent  new  growths.  In  these  organs 
the  lymphoid  parenchyma  is  choked  and  replaced  by  myeloid  tissue. 
The  mucous  and  serous  membranes  are  not  affected  as  they  are  in  the 
lymphocytomatoses. 

Because  of  the  increased  number  of  cells  of  the  granular  system  which 
appear  in  the  circulation  in  the  myelo-cytomatoses  the  terms  leucemic 
myelo-cytomatosis  or  myeloid  leucemia  are  employed. 

Cases  of  this  rare  form  of  disease  have  been  definitely  diagnosed  after 


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the  sixth  year.4    Almost  all  of  them  have  a  chronic  course  extending  over 
several  months  or  years  and  have  proved  fatal. 

Symptoms. — The  first  definite  symptoms  are  usually  those  of  mechanical 
origin,  resulting  from  the  size  of  the  tumor  and  the  pressure  of  the  hard, 
rough  spleen,  which  gradually  grows  to  an  enormous  size.  Even  then,  the 

general  well-being  and  the  appearance  of  health 
may  continue  for  a  time.  Later,  as  a  result  of 
hemorrhage,  symptoms  of  cachexia  and  signs  of 
anemia,  such  as  pallor,  lassitude,  dyspnoea,  palpi- 
tation, anorexia,  and  loss  of  weight  appear. 
Coincidently,  spontaneous,  and  pressure  pains  in 
the  bones  develop  and  alterations  of  hearing  and 
a  hemorrhagic  retinitis  are  observed.  The  urine 
shows  protein,  casts,  and  increased  output  of  uric 
acid.  Moderate  swelling  of  the  superficial  and 
deep  lymph  nodes  often  occurs,  but  only  after  the 
long  continuance  of  the  disease.  Irregular  rises 
in  temperature  are  frequent. 

If  the  blood  is  highly  leucemic,  its  increased 
viscidity  and  diminution  of  color,  together  with 
the  formation  of  a  grayish-white  sediment  upon 
standing,  and  its  slow  coagulation,  may  be  noted, 
but  less  distinctly  than  in  lymphemia.  The 
anemia  is  usually  of  a  simple  normoblastic  type; 
less  commonly  it  may  be  megaloblastic.  The 
degree  of  the  anemia  varies  greatly.  The  number 
of  white  cells  is  usually  between  100,000  and 
400,000.  All  forms  of  cells  of  the  granular  system 
take  part  in  the  absolute  increase,  so  that  the 
blood  looks  as  though  bone-marrow  had  passed 
into  the  circulation.  Myelocytes  of  the  most  vari- 
able types  of  granulation  are  relatively  numerous, 
ranging  to  about  fifty  per  cent.  Occasionally,  the 
eosinophilic  and  basophilic  granular  leucocytes  are 
also  relatively  increased.  The  neutrophilic  granu- 
lar polymorphonuclear  cells  are  usually  present  in 
but  slight  excess.  The  appearance  of  myeloblasts 
and  abnormal  cells  toward  the  end  of  the  disease 
is  a  noteworthy  fact. 

Diagnosis. — Difficulties  in  diagnosis  are  encountered  when  the  blood 
picture  and  the  splenic  enlargment  have  been  affected  by  complicating  con- 
ditions or  by  therapy.  A  high  leucocytosis  in  anemic  patients,  arising  from 
such  causes  as  sepsis  and  granulomatosis,  is  to  be  considered.  In  these 
cases,  however,  the  blood  picture  is  less  varied  and  the  increase  of  the 

4  In  younger  children,  in  whom  a  diagnosis  of  myeloid  leucemia  has  been  accepted, 
the  process  was  probably  always  that  of  Jaksch's  anemia.  Reports  in  recent  literature 
seem  to  indicate  that  this  form  is  more  common  than  was  formerly  believed. 


FIG.  37.  — Myeloid  leucemia, 
boy  of  twelve  years;  Intermis- 
sion with  disappearance  of  all 
symptoms  under  treatment  with 
arsenic  and  X-Ray. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS 


181 


eosinophiles  and  the  mast  cells  is  also  wanting.  For  practical  purposes  the 
disease  may  be  differentiated  from  Jaksch  's  anemia  (which,  both  clinically 
and  pathologically,  differs  only  in  quantitative  degree  from  myeloid  leu- 
cemia),  by  the  minimal  age  limit  in  the  occurrence  of  the  former  to  five  years. 
Occasionally,  at  least,  myelo-cytomatoses  may  take  a  sub-  or  aleucemic 
course,  and  hence  the  use  of  the  term  myeloid  pseudoleucemia. 

4.    MYELOSARCOMATOSES 

The  myelosarcomatoses,  or  multiple  aggressive  myelomata,  developing 
both  within  and  without  the  bone-marrow,  are  of  a  type  of  disease  which 
does  not  occur  in  childhood 

CHLOROMATA 

The  chloro- lympho- and  chloro- myelosarcomata,  which  maybe  regarded 
as  deviations  from  the  lympho-  or  myelo-cytomatoses,  or  as  forms  of  the 
latter  pursuing  a  peculiar  course,  are 
relatively  common  in  early  life.  They 
present,  at  times,  the  characteristics  of 
leucemia,  but  occur  more  often  without 
them.  Most  of  the  cases  of  chloroma 
observed  have  been  in  young  males 
ranging  from  two  to  thirty  years.  One- 
half  of  these  have  been  in  children. 

The  chloromata  are  distinguished 
pathologically  from  the  corresponding 
leucemias  and  pseudoleucemias  by  ex- 
tensive, generalized,  subperiosteal  cell 
proliferation.  For  some,  as  yet  un- 
known reason,  these  proliferations  are 
often  of  a  yellow  or  grayish-green  color. 
They  are  most  commonly  found  in  the 
flat  bones  of  the  cranium,  especially  in 
the  orbital  region,  the  temporal  bones, 
and  the  zygoma,  and  in  the  bones  of 

the  thorax.    Similar  proliferation  occurs,  less  frequently,  in  the  skin  and 
serous  membranes. 

Clinically  they  are  distinguished  by  the  formation  of  symmetrical 
tumors,  growing  within  the  cranial  cap,  the  spinal  canal,  the  mouth,  and 
the  mastoid  cells;  and  causing  such  pressure  symptoms  as  protrusion  of  the 
optic  bulb,  paralyses  of  cranial  nerves,  etc.  These  characteristic  clinical 
signs  develop  early.  Their  aggressive  character  gives  the  chloromatous 
diseases  a  position  between  the  cytomata  and  the  sarcomata.  In  other 
respects  their  clinical  and  pathologic  findings  correspond  closely  to  those 
of  the  common  forms  of  lymphocytomatoses  or  myelo-cytomatoscf?.  Their 
course  is  always  acute  and  very  severe.  The  duration  of  the  disease  is,  at 
least,  a  matter  of  a  few  months. 


FIG.  38. — Three  and  one-half-year-old  boy 
with  chloromatous  tumors  on  the  flat  cranial 
bones,  vertebra,  and  orbits,  with  hyperplasia 
of  the  lymph  nodes  and  anemia. 


182 


TEXT-BOOK  OF  PEDIATRICS 


5.  GRANULOMATOSES 

Granulomatoses  are  formed 'by  chronic  inflammatory  processes  which 
gradually  develop  hard,  compact,  granulation  tumors  of  the  lymph  nodes, 
with  a  tendency  to  necrosis,  induration,  and  scar  formation,  without  lym- 
phocytic  proliferation  or  aggressive  growth.  Essentially  they  consist  of 
endothelial  and  epithelial  cells,  of  giant,  spindle,  and  round  types,  mixed 

with  fibroplastin  and  fibrin.  The 
granulomata  may  be  genera- 
lized from  the  beginning,  or 
persistently  localized.  The  lym- 
phatic tissue  of  the  spleen  and 
the  liver  is  usually  affected  dur- 
ing the  course  of  the  disease, 
while  that  of  other  organs,  as 
the  bone-marrow  is  but  rarely 
involved. 

Symptoms. — At  first,  soft, 
grape-like  enlargments  of  the 
lymph  nodes  appear  in  the  neck. 
These  may  be  unilateral  or 
successively  bilateral.  Signs  of 
pressure  in  the  mediastinum  are 
soon  apparent.  In  the  diffuse 
form,  enlargement  of  the  spleen 
and  liver  follows  the  gradual 
hardening  of  the  enlarged  lymph 
nodes.  Periods  of  severe  inter- 
mittent fever,  occurring  even 
in  tuberculous  individuals,  are 
characteristic.  The  suspicion  of 
granulomatosis  is  definitely 
sustained  by  a  persistent  diazo- 
rcaction  of  the  urine.  The  diag- 
nosis is  fully  established  in  the 
living  by  the  histologic  exam- 
ination of  an  excised  gland. 
The  diffuse  type  of  the  disease 
runs  a  chronic  course,  unaffected  by  treatment,  producing  anemia  and  ca- 
chexia,  and  always  ends  fatally. 

The  localized  forms,  and  especially  those  occurring  in  luetic  patients,  are 
amenable  to  treatment.  In  contradistinction  to  scrofulous  lymphadenitis, 
the  granulomata  do  not  tend  to  form  epidermal  scars  or  perforations,  and 
have  no  relation  to  regional  diseases  of  the  skin  and  mucous  membranes. 


FIG.  39.  — Seven  and  one-half-year-old  boy  with  granulo- 
matosis,  most  marked  in  the  cervical  nodes.  Confirmed 
by  histological  examination. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  183 

PATHOGENESIS  or  LEUCEMIA  AND  PSEUDOLEUCEMIA 

Myelo-cytomatosis  occurs  physiologically  in  the  embryo  in  practically 
the  same  manner  as  does  myeloid  leucemia.  It  develops  after  birth  by  a 
metaplasia  due  to  the  action  of  infectious,  toxic,  or  actinic  stimuli.  This  is 
equally  true  of  embryonic  lymphocytomatosis,  which  differs  only  quanti- 
tatively from  lymphoid  leucemia.  Upon  these  facts  (Naegeli),  our  knowl- 
edge of  the  pathogenesis  of  the  leucemic  diseases  is  based.  Their  etiology 
is  entirely  obscure.  Some  forms  of  pathologic  leucopoiesis,  as  initially  noted 
hi  the  evolution  of  myelocytes  in  osteosclerosis,  may  be  considered  purely 
compensatory.  In  others,  as  in  the  formation  of  myelocytes  in  post-hemor- 
rhagic,  toxogenous  or  infectious  anemia,  the  increased  requirement  or 
demand  may  be  a  factor.  In  still  others,  a  direct,  specific  stimulative  action 
of  endogenous  or  ectogenous  substances,  serving  as  specific  excitants,  may 
play  a  part. 

The  granulomata  are,  in  some  cases,  directly  dependent  upon  syphilitic 
poison  and,  in  others,  upon  a  tuberculous  infection  (Sternberg).  The 
granular  form  due  to  the  tuberculous  virus  (Much-Romer),  is  especially 
common.  In  another  group  of  these  cases — the  malignant  granulomatoses 
— however,  neither  a  syphilitic  nor  a  tuberculous  infection,  nor  any  other 
known  cause,  can  be  demonstrated. 

THERAPY 

There  is  no  specific  treatment  for  the  leucemias  of  childhood.  It  is 
possible,  especially  in  myelo-cytomatosis,  to  cause  a  direct  destruction  of  the 
white  cells  in  the  circulation  and  to  combat  their  excessive  formation  and 
appearance  in  the  circulation  by  limiting  the  cytogenesis.  In  the  early 
stages  of  the  disease  it  is,  strangely  enough,  not  uncommon  to  note,  not 
merely  the  remarkable  disappearances  of  blood  symptoms,  but  improve- 
ment in  other  manifestations  of  the  disease  and  in  the  general  well-being. 
Relapses  always  occur.  These  temporary  results,  which  serve  to  prolong 
life,  are  in  all  probability  similar,  in  all  essentials,  to  the  beneficial  action  of 
intercurrent  infectious  diseases.  Benefit  is  quite  certainly  and  directly 
secured  by  the  use  of  arsenic  in  the  form  of  the  liquor  potassii  arsenitis 
(Fowler's  solution),  in  doses  up  to  twelve  drops  a  day,  continued  for  months. 
More  recently  benzol  has  given  good  results.  Similar  improvement  has  been 
obtained  by  the  use  of  the  Roentgen  rays,  applied  in  from  two  to  six  treat- 
ments, over  the  spleen  and  the  region  of  groups  of  affected  lymph  nodes. 
A  hard  tube  should  be  used,  placed  at  least  40  cm. (16  inches),  from  the  body, 
and  the  exposures  should  last  from  five  to  ten  minutes.  Symptoms  of  arsen- 
ical poisoning  and  toxogenic  anemia  may,  of  course,  appear,  while  with  the 
Roentgen  method  there  is  always  danger  of  dermatitis.  In  both  forms  of 
treatment  violent  reactions  may  be  harmful,  resulting  in  fever  and  fatality. 
The  most  careful  dosage  and  an  extreme  watchfulness  will  protect  the 
patient  absolutely  against  these  accidents.  A  criterion  of  judgment  of 
therapeutic  action  is  to  be  found  in  a  careful  observation  of  the  numbers  of 
red  cells  and  of  the  hemoglobin  index  of  the  blood,  and  in  a  determination 


184  TEXT-BOOK  OF  PEDIATRICS 

of  the  output  of  endogenous  uric  acid.  It  must  be  remembered,  however, 
that  in  these  cases  the  full  effects  of  the  Roentgen  ray  usually  develop  after 
several  days. 

In  cases  of  aleucemic  lymphadcnosis  and  myclosis,  and  especially 
in  cases  of  tymphosarcomata,  every  experienced  observer  has  occasionally 
seen  the  most  surprising  results  under  these  methods  of  treatment. 
Whether  complete  recovery  ever  takes  place  is  still  doubtful.  The  treat- 
ment of  diffuse  granulomata  is  hopeless.  Local  granulomata  may  be  excised 
or  treated  with  iodine,  the  internal  and  external  application  of  which  are 
often  successful.  This  obtains,  however,  only  when  the  luetic  character  of 
the  tumor  does  not  indicate  other  forms  of  treatment. 

HEMORRHAGIC  DIATHESIS  OR  TENDENCY  TO  HEMORRHAGE 

In  text-books  it  is.  not  customary  to  group  diseases  according  to  their 
symptoms,  but  the  diseases  to  be  discussed  under  this  title  are  so  grouped 
because  of  the  greater  convenience  for  study  and  for  use  in  actual  practice. 
The  diseases  are  not  necessarily  related,  either  in  their  nature  or  general 
manifestations.  The  grouping  followed  is  based  upon  the  more  outstanding 
symptoms  with  which  hemorrhage  may  be  combined. 

Group  I.  Purpura  Hemorrhagica. — The  diseases  in  this  group  are 
limited  rather  narrowly  to  those  in  which  the  tendency  to  hemorrhage  is 
secondary  to  such  blood  diseases  as  leucemia  and  the  anergic  nonplastic 
anemias.  The  most  frequently  seen  is  the  symptom  group  first  described 
by  Werlhof  and  known  as  Werlhof 's  disease.  The  primary  conditions  may 
be  true  blood  diseases  with  characteristic  findings,  or  may  be  of  more 
indefinite  and  unexplained  nature.  In  the  latter  cases  the  tendency  to 
hemorrhage  appears  as  an  "idiopathic  morbus  Werlhoffi, "  that  is,  it  is  the 
outstanding  feature  of  the  entire  symptom-complex.  In  all  the  diseases  of 
this  group  the  course  of  the  tendency  to  hemorrhage — unless  death  results 
from  loss  of  blood — is  dependent  entirely  upon  the  primary  blood  disease,  so 
that  it  may  be  acute  and  rapidly  fatal,  or  a  relatively  chronic,  benign  affair 
with  complete  recovery  or  with  intermissions.  The  idiopathic  form  may 
also  run  a  course  of  continual  aggravation  or  of  gradual  recovery. 

The  hemorrhages  may  be  from  the  skin  and  subcutaneous  or  from 
mucous  membranes  or  into  muscles,  but  very  rarely  synovial.  They  occur 
as  petechias,  or  larger  spots  following  slight  trauma,  are  asymmetric  and 
are  seen  even  on  the  head  and  face.  The  hemorrhages  from  the  mucous 
membranes  of  the  nose,  mouth,  vagina  and  at  times  of  the  bowel  are  char- 
acteristic. They  may  be  very  profuse  and  even  fatal.  There  are  no  local 
symptoms  and  the  general  symptoms  are  closely  interwoven  with  the 
symptoms  of  the  primary  affection  and  the  post-hemorrhagic  anemia. 
The  bleeding  time  is  prolonged  and  the  contraction  of  the  clot  is  incomplete. 
During  the  height  of  the  hemorrhagic  tendency  the  number  of  blood-plate- 
lets in  the  circulating  blood  is  reduced  to  30,000  or  even  lower.  From  a 
pathogenetic  standpoint  great  stress  is  laid  upon  this  "  thrombopenia "  in 
view  of  the  action  of  the  platelets  in  the  mechanism  of  coagulation.  Accord- 
ing to  these  findings,  the  cases  of  hemorrhagic  purpura  of  the  Werlhof  type 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  185 

must  be  considered  due  chiefly  to  hematic  causes.  The  thrombopenia  may 
occur  with  the  various  intercurrent  diseases  and  in  various  ways  analogous 
to  the  origin  of  anemias.  Its  pathogenesis  is  probably  analogous  to  that  of 
certain  primary  anemias.  In  some  cases  it  may  be  due  to  a  crowding  out 
of  the  platelet-forming  parenchyma  in  the  bone-marrow  by  leucemic 
lymphoid  proliferation.  In  others,  a  marked  restriction  of  the  develop- 
ment of  bone-marrow.  Or  again  increased  thrombocytolosis  in  the  spleen 
or  its  associated  tissue  due  to  hyperplasia.  Further,  a  congenital  deficiency 
of  the  platelet-forming  marrow  in  a  condition,  no  doubt,  related  to  familial 
hemophilia  for  which  Glauzmann  has  suggested  the  name  "  hereditary 
thrombasthenia "  may  be  a  factor.  The  action  of  blood  poison  of  all  sorts 
may  be  causative.  Since  infectious  diseases  may  also  cause  a  thrombopenia 
either  directly  or  indirectly  by  the  action  of  toxins,  this  type  of  hemor- 
rhagic  diathesis  is  also  seen  as  a  concomitant,  or  complication  of  these  and 
more  especially  after  scarlet  fever  and  diphtheria. 

In  the  treatment  of  these  conditions  transfusions,  injections  of  auto- 
serum,  subcutaneous  injections  of  horse  serum  and  salt  solution,  and  various 
commercial  coagulation  producing  products  are  recommended.  Internally, 
liquor  potassii  arsenitis  (Fowler 's  solution)  in  increasing  doses  up  to  twenty 
drops  per  day,  calcium  lactate  or  preferably  chloride  in  large  doses  (6-10 
grams  per  day)  and  gelatin  either  subcutaneously  in  ten  per  cent,  solution^or 
in  large  amounts  by  mouth  are  useful.  The  use  of  Roentgen  treatments  to 
the  spleen  is  indicated  when  that  organ  is  enlarged. 

Group  II.  Hemorrhage  due  to  Multifocal  Infectious  Disease. — This 
group  is  characterized,  clinically,  by  the  close  relationship  to  obvious  infec- 
tious diseases  such  as  meningococcus  meningitis,  measles,  influenza,  sepsis, 
chicken-pox,  tuberculosis  and  congenital  lues.  In  these  conditions  we  may 
have  multiple,  circumscribed,  more  or  less  autonomous  disease  foci  in  the 
peripheral  vessels,  resulting  in  emboli,  thromboses,  hemorrhagic  exuda- 
tions, and  erosions  of  the  vessel  walls  which  in  turn  cause  bleeding.  So 
that  the  hemorrhagic  tendency  in  these  conditions  is  largely  due  to  organic 
vascular  lesions.  Its  occurrence  is  in  association  with  and  dependent  upon 
the  basic  infectious  disease. 

Group  HI.  Hemorrhagic  Arthritis  (Schoenlein-Henoch). — This  group 
consists  of  diseases  with  a  rather  definite  symptom  picture.  It  occurs  most 
frequently  in  older  children,  and  is  not  fatal.  They  are  characterized  by 
recrudescences  lasting  several  days  or  weeks  and  the  entire  course  lasting 
for  weeks  or  months.  In  definite  cases  a  symptom  triad  predominates. 
This  consists  of  cutaneous  purpura,  intestinal  colic,  and  articular  pains 
with  or  without  swelling  of  the  joints.  All  these  symptoms  are  supposed  to 
be  due  to  hemorrhage  or  the  results  of  hemorrhage.  The  subcutaneous 
hemorrhages  are  petechial  or  may  become  as  large  as  small  coins,  super- 
ficial, and  are  more  or  less  symmetrical  on  trunk  and  limbs.  Actual  bleed- 
ing is  uncommon.  Frequently  skin  eruptions,  edema  and  proteinuria  is 
encountered.  The  skin  eruption  may  be  urticarial,  erythematous  or  mul- 
tiform in  type.  There  may  be  no  fever  and  the  general  manifestations  are 
usually  mild.  The  etiology  is  entirely  unknown,  but  the  theory  of  an 


186  TEXT-BOOK  OF  PEDIATRICS 

infectious  or  anaphylactic  nature  is  generally  accepted  but  far  from  proved. 
It  is  supposed  that  a  functional  vascular  injury,  that  is  a  toxic  capillary 
paralysis  with  dilatation  and  diapedesis,  is  concerned  in  the  causation. 
Usually  no  treatment  other  than  rest  in  bed  is  necessary.  The  remedies 
advised  under  purpura  hemorrhagica  may  be  employed. 

Group  IV.  Scurvy. — In  this  group  there  is  a  distinct  relation  between 
the  hemorrhagic  tendency  and  food  deficiency  as  shown  by  its  prompt 
reaction  and  relief  by  diatetic  treatment.  True  scurvy  has  been  very  uncom- 
mon in  civilized  countries,  but  during  the  World  War  was  again  quite  fre- 
quent in  the  countries  where  lack  of  proper  food  occurred.  Infantile  scurvy, 
Barlow's  disease,  in  children  under  two  years  is  not  rare  at  any  time. 
According  to  recent  investigations  the  two  conditions  are  closely  related. 
Their  manifestations  differ  because  the  immature  osseous  system  of  the 
infant  reacts  differently  to  the  injury  than  does  that  of  older  patients.  It  is 
still  doubtful  whether  this  injury  is  primarily  one  of  the  bone-marrow  itself 
or  whether  it  is  due  to  vascular  changes  affecting  the  marrow. 

INFANTILE  SCURVY   (Barlow's  Disease) 

This  condition  is  of  great  interest  to  the  pediatrist  and  requires  full  dis- 
cussion here.  The  scurvy  of  adults  is  left  for  text-book  of  internal  medicine. 

Etiology. — Naegeli  and  other  authors  suggest  as  a  cause  of  the  symptoms 
a  reduced  proliferation  of  the  interstitial  connective  tissue  of  the  marrow, 
with  transition  of  marrow  cells  into  fibrous  connective  tissue  at  certain 
points  of  most  rapid  growth  as  in  the  diaphyses,  costochondral  margins  and 
cranial  bones.  This  is  supposed  to  have  two  results. 

First. — The  activity  of  the  osteoblasts  and  the  resulting  bone  growth  is 
reduced  at  the  affected  points.  With  continuing  resorption  of  the  already 
formed  bone,  the  wall  becomes  thinned  resulting  in  localized  weakness  or 
myelogenous  infantile  osteotabes.  Muscular  action  and  slight  trauma 
cause  infractions  and  fractures  of  the  diaphyses  of  long  bones  and  the  ribs. 
The  growth  in  length  is  delayed.  (Figs.  40  and  41.) 

The  bone  affection  described  above  differs  entirely  from  true  rickets. 
The  addition  of  rickets,  however,  may  add  to  the  fragility  of  the  diseased 
ends  of  the  diaphyses.  In  contradistinction  to  rickets,  the  mineral  salts, 
especially  calcium,  are  found  to  be  retained  in  infantile  scurvy  and  are 
liberated  when  diatetic  treatment  is  instituted.  During  the  florid  stage,  the 
mineral  content  of  the  bones  and  muscles  is  low. 

Second. — The  hematopoietic  function  of  the  bone-marrow  suffers.  The 
result  of  this  is  progressive  anemia  and  a  tendency  to  hemorrhage.  The 
latter  is  especially  seen,  in  the  event  of  fracture,  in  the  development  of 
subperiosteal  and  medullary  hemorrhages.  The  tendency  to  bleeding  shows 
itself,  also,  at  other  points. 

Symptoms. — The  osteotabes  causes  severe  pains  in  the  affected  bones; 
deformities  and  crepitation;  distension,  with  dough-like  swelling  of  the  soft 
parts  from  the  underlying  blood  deposits;  and  tenseness  of  the  skin.  Severe 
pain  is  localized  principally  at  the  ends  of  the  diaphyses  and  is  excited  by 
movement  or  touch.  As  a  result  there  may  be  a  degrae  of  pseudoparalysis, 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  187 

but  this  is  not  a  constant  sign  (Fig.  43).  Deformities  appear  in  the  affected 
bones  and  especially  in  those  of  the  fore-leg  and  the  thigh,  at  the  knee-joint, 
and  more  rarely  in  the  bones  of  the  arm  and  forearm,  at  the  elbow  or 
shoulder-joint,  and  at  the  costochondral  articulations.  The  sinking  in  of 


Flo.  40. — Humerus  of  a  child  of  one  year  Fio.  41.  — Femur  of  child,   infantile  scurvy.     Hempr- 

with  infantile  scurvy.     The  soft  parts  have  rhage  into   the  marrow   and   subperiosteal   tissue  with 

been  dissected  away  in  order  to  show  the  loosening  of  the  periosteum, 
impacted  fracture  of  the  neck  more  clearly. 

the  sternum  with  the  costal  cartilages  is  a  good  example  of  the  deformities 
which  may  arise. 

In  the  mucous  membranes  the  hemorrhagic  diathesis  is  manifested 
commonly  by  hemorrhagic  swelling  and  softening  of  the  gums.  These  occur 
only  when  the  teeth  are  present  or  are  erupting.  It  is  further  indicated  by 
conjunctiva!,  nasal,  intestinal  and  urinary  bleeding;  the  two  latter  sources 
being  shown  by  bloody  stools  and  hematuria.  Extensive  extravasations  of 
blood,  of  both  subperiosteal  and  supraperiosteal  origin  appear  in  the  jaw 
and  in  the  long  bones  affected.  Hemorrhage  of  the  periosteum  of  the 
orbital  plate  is  recognized  by  exophthalmos  and  by  infiltration  of  the  eye- 


188 


TEXT-BOOK  OF  PEDIATRICS 


lids;  while. bleeding  from  the  parietal  periosteum  is  recognized  by  the  forma- 
tion of  ceph'alhematomata.  In  the  skin,  pallor,  petechise,  suffusionsand  edema 
are  accepted  signs  of  anemia.  In  a  small  number  of  cases  blood  changes, 
in  the  form  of  oligochromemia,  oligocythemia,  poikilocytosis  and  relative 
lymphocytosis,  may  be  determined  by  examination.  Tachypncea,  tachy- 
cardia, caidiac  murmurs  and  dilatation  of  the  heart  may  also  develop. 
A  typical  fever  frequently  appears  and  is  probably  due  to  the  resorption  of 
extravasated  blood.  Food  is  often  entirely  refused. 

Scurvy  usually  presents  itself  to  the  observer  in  the  following  manner. 
After  very  slight  prodromes,  such  as  disturbances  of  sleep  and  disposition, 
marked  thirst,  and  loss  of  color,  and  sometimes  even  without  these,  one 
notices,  usually  during  the  bath  or  while  handling  the  child,  that  it  gives 
evidences  of  pain  upon  being  touched  and  especially  in  the  legs.  Soon  after, 
swelling  of  the  knee,  on  one  or  both  sides,  and  of  the  ankles  becomes  appar- 

^. ent.    The  type  of  the  deformity  is 

different,  however,  from  that  pro- 
duced by  hemorrhage  into  the  joint 
cavity.  It  is  clearly  a  disease  of  the 
long  bones  themselves.  The  legs 
are  held  motionless  upon  the  bed, 
in  external  rotation,  with  abducted 
thighs  and  slight  flexion  of  the 
knees.  A  few  days  later,  a  spongy 
thickening  of  the  gums  around  the 
teeth,  or  beside  the  teeth  which  are 
erupting,  is  to  be  noticed.  At  the 
same  time,  small  hemorrhages,  re- 
sembling flea-bites  or  larger  suffu- 
sions of  blood  are  seen,  here  and 
there,  upon  the  skin.  The  mother 
reports  a  peculiar  red  discoloration 
of  the  soiled  diaper  and  a  sediment,  consisting  of  erythrocytes,  appearing 
in  the  fresh  urine.  The  latter  may  even  present  the  characteristic  findings 
of  acute  hemorrhagic  nephritis.  The  general  condition  of  the  patient  be- 
comes more  serious,  the  face  increasingly  pallid,  the  restlessness  more 
marked,  while  the  immobility  of  the  limbs — consequent  upon  the  suffer- 
ing heightens  the  impression  of  extreme  debility. 

Diagnosis. — The  affection  of  the  gums,  the  pseudoparalytic  symptoms, 
the  painful  swelling  of  the  limbs,  together  with  the  hematuria  and  hemato- 
mata  are  especially  significant  in  the  diagnosis  of  scurvy.  The  combination 
of  the  hemorrhagic  diathesis  with  multiple  lesions  of  the  bones,  associated 
with  certain  external  conditions,  is  almost  pathognomonic.  However, 
hematuria  is  occasionally  the  only  symptom.  The  Roentgenogram  may  be 
very  characteristic.  It  shows  a  dark  shadow  strip  at  the  border  of  the 
diaphyses  and  may  also  show  the  shadow  of  blood  extravasates  under  the 
periosteum  along  the  shaft.  (Fig.  44.) 


FIG.    42. — Changes  in  the  gums  in  a  case  of  in- 
fantile scurvy. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS          189 

Course  and  Prognosis. — The  onset  is  usually  gradual  and  is  marked  by  a 
certain  disturbance  of  nutrition,  its  most  delicate  symptom.  Its  typical 
qualities  appear  successively.  Untreated,  the  disease  is  chronic  and  is 
slowly  progressive  for  months.  Recovery  may  take  place  spontaneously 
in  mild  cases.  The  severer  forms  are  usually  supposed,  however,  to  be  fatal, 
terminating  in  enteritis  or  pneumonia.  The  prognosis  depends  upon  the 
skill  of  the  attending  physician. 

Occurrence  and  Etiology. — The  great  majority  of  cases  begin  from  the 
ninth  to  the  fifteenth  month.  Cases  that  develop  at  a  late  period,  say,  dur- 
ing the  second,  third  or  even  the  fourth  year,  or  those  beginning  earlier  in 
the  third  to  the  fifth  month,  are  much  rarer.  The  disease  is  more  frequent  in 


FIG.  43. — Position  of  the  thighs  in  infantile  scurvy. 


Germany  and  in  the  north  of  Europe  than  it  is  in  the  south.  In  some 
southern  countries  it  is  almost  unknown.  This  infrequency  is  actual  and 
is  not  due  to  any  want  of  recognition.  It  seems  to  spread  from  the  northern 
latitudes  (see  Rickets).  Male  children  are  affected  almost  exclusively  and 
especially  those  who  are  fed  entirely,  or  to  a  large  extent  on  commercially 
prepared  and  sterilized  milk  or  other  artificial  food.  For  this  very  reason, 
scurvy  is  uncommon  among  the  poorer  classes.  It  goes  without  saying  that 
not  all  children  so  fed  are  affected,  but  only  those  with  a  definite  predis- 
position. None  of  the  hypotheses,  of  course,  such  as  injury  to  the  milk  by 
heating,  by  bacteria  or  bacterial  toxins,  by  icing  and  storage,  or  by  silicic 
acid  derived  from  glass  containers,  are  tenable.  In  fact,  the  attempt  to 
classify  scurvy  among  disturbances  of  nutrition  results  in  stretching  out 
conceptions  of  the  disease  beyond  all  reason. 


190 


TEXT-BOOK  OF  PEDIATRICS 


Therapy. — Since  Barlow  first  recognized  scurvy  there  has  been  no 
disease  of  childhood  that  has  proved  so  gratifyingly  amenable  to  simple 
treatment.  Nor  is  there  a  disease  of  this  period  upon  the  course  of  which 

pediatric  ignorance  has  had 
more  serious  results.  It  has  been 
mistaken  for  rickets,  osteomy- 
elitis, fungus,  syphilis  and  sepsis. 
In  its  treatment,  natural 
foods,  such  as  raw  cow's  milk, 
or  human  milk ;  several  dessert- 
spoonfuls of  fresh  orange,  lemon, 
or  grape  juices,  each  day;  ripe, 
finely  divided  fruits,  such  as 
apples  in  season ;  mashed  vege- 
tables, or  raw  meat  juices  should 
be  given.  Intestinal  catarrh  is 
no  contraindication  for  these 
foods.  The  results  of  their  use 
are  truly  miraculous.  They  are 
subjectively  recognized  in  a 
very  few  days  and  all  objective 
symptoms  disappear  in  a  few 
weeks.  The  repair  of  severe 
bone  lesions  requires,  however, 
several  months.  Fractures  do 
not  require  supporting  splints, 
since  the  remaining  periosteum 
seems  to  suffice  to  keep  the 
bones  in  place.  Baths,  antiphlo- 
gistic applications,  and  all  un- 
necessary handling  of  the  child 
should  be  avoided. 

Certain  mechanical  disturb- 
ances of  circulation  may  lead 
to  hemorrhage  as  in  case  of  con- 
gestion due  to  cardiac  decom- 
pensation or  diseases  with  convulsions  or  coughing.  Besides  this  severe 
cachectic  processes,  many  organic  nervous  disorders,  even  psychic  influences 
may  give  an  increased  tendency  to  bleed.  The  hemorrhagic  diseases  of  the 
new-born  will  be  discussed  in  another  section. 

RICKETS 

Pathologic-Anatomy. — The  most  important  pathologic  changes  in 
rickets  are  those  of  the  skeleton.  In  the  acute  stage  we  find,  macroscopi- 
cally  a  more  or  less  general  softening  of  the  bones,  which  become  deformed 
by  swelling,  decurvation  and  formation  of  callus.  The  periosteum  and 
bone-marrow  are  hyperemic.  Over  some  bones  especially  those  of  the  cra- 


FIG.  44. — Roentgen  picture  of  the  right  thigh  of  a  girl 
of  one  year  with  scurvy.  Subperiosteal  hemorrhages  of 
the  femur. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  191 

nium,  the  periosteum  may  become  so  greatly  thickened  as  to  resemble  a 
spongy  exudate. 

The  most  important  microscopic  findings,  also  are  seen  in  the  bony 
framework  and  are  as  follows : 

1.  The  bone  and  cartilage  formed  during  the  progress  of  the  disease  are 
insufficiently  calcified  or  entirely  uncalcified,  so  that  in  acute  rickets, 
non-calcified  cartilage  and  bone  tissue,  the  so-called  osteoid  tissue,  of  much 
greater  thickness  or  width  than  normal,  is  found  throughout  the  skeleton. 
This  especially  is  seen  in  those  parts  where,  normally,  the  growth  is  partic- 
ularly active,  as  in  the  periosteum  and  in  the  subchondral  zones.    The  new 
formation  of  osteoid  tissue  occurs  at  an  abnormal  rate  in  these  parts.  At  the 
diaphyses,  the  points  where  tendon  insertion  and  muscular  attachment 
constantly  subject  the  bones  to  extreme  flexion  or  extension,  the  mechanical 
insufficiency  due  to  the  extreme  softness  of  the  osteoid  tissue  leads  to  an 
attempt  at  compensation  by  excessive  new  formation  of  bone,  or  by 
decreased  resorption  of  it.    This  active  proliferation  and  mass  formation  is 
probably  a  secondary  manifestation  and  naturally  occurs  as  a  result  of 
increased  vascularity.    This  is  known  as  Kassowitz'  inflammation,  rickitic 
osteitis,  or  periosteitis.    When  this  condition  is  most  marked  it  is  described 
as  a  hyperplasic  osteophytic  form  of  rickets. 

2.  Bones,  which  at  the  onset  of  the  disease  were  completely  formed, 
become  poorer  in  calcium  salts  and  therefore  softer  (osteomalacia).    This 
decalcification  must  not  be  considered  analogous  to  that  produced  in  the 
treatment  of  bone  with  acid,  to  make  it  easier  to  cut,  as  was  once  taught. 
It  is  not  a  chemical  decalcification.    It  occurs,  rather,  as  an  actual  biologic 
process,  by  which  the  physiologic  resorption  of  the  older  portions  of  the 
bone  tissue  continues,  while  the  absorbed  portions  are  replaced  by  newly- 
formed  tissue,  poor  in  calcium  or  containing  no  calcium  at  all,  so  that  the 
removal  of  the  lime  salts  in  the  mature  bone  is  actually  a  result  of  the  non- 
calcification  of  the  osteoid  tissue,  described  in  previous  paragraphs.    It  is 
entirely  comparable  to  the  decalcification  which  occurs  in  osteomalacia. 
It   is,  accordingly,  most  pronounced  in  those  parts  in  which  the  bone 
is  normally  thin,  as  in  the  craniotabetic  areas  on  the  posterior  aspect  of 
the  skull.     The  loss  of  the  salts  in  rickets  may  convert  the  long  bones 
into  rubber-like,  elastic  strands  that  are  easily  severed — the  osteomalacic 
form  of  rickets. 

According  to  von  Recklinghausen  this  softening  of  mature  bones  takes 
place  at  a  rapid  rate  in  rickets.  It  goes  on  in  circumscribed  areas  and  is 
produced  by  the  tryptic  autolytic  action  of  the  osteoclasts  and  newly 
formed  vessel  shoots. 

3.  The  endochondral  ossification  is  disturbed  in  an  equally  character- 
istic manner.    The  preliminary  calcification  of  the  cartilage  is  wanting,  and 
under  markedly  increased  vascularity  the  zone  of  cartilage  proliferation 
becomes  irregular  in  form  and  greatly  extended.     This  extension  arises 
from  the  delayed  resorption,  which  in  turn  is  due  to  the  disturbance  of 
calcification.     The  impairment  of  the  endochrondral  ossification,  character- 
istic of  rickets,  is  closely  related  to  the  longitudinal  growth  of  the  bone 


192  TEXT-BOOK  OF  PEDIATRICS 

during  the  course  of  the  disease.  In  consequence,  it  is  absent  in  the  osteo- 
malacia  of  adults.  In  a  word,  the  disturbances  of  ossification  are  due 
entirely  to  the  non-calcification  of  both  cartilage  and  bone. 

4.  Occasionally,  fibrous  foci  have  been  found  in  the  bone-marrow  of 
rickitic  children.  Recently,  however,  Marfan,  in  opposition  to  older 
observers,  has  held  that  the  changes  in  the  bone-marrow  in  rickets  are 
constant  and  pathogenetically  of  great  importance  (see  below).  According 
to  this  observer,  the  first  or  clinically  latent  stage  of  rickets  is  characterized 
by  an  irritative,  atypical  and  aberrant  proliferation  of  the  cells  of  the  par- 
enchyma of  the  bone-marrow  and  of  the  cartilage.  The  second  and  clini- 
cally manifest  phase  is  characterized  by  the  formation  of  a  fibrous  marrow 
(see  Scurvy).  Ziegler,  also,  considers  the  proliferation  of  the  cells  of  the 
bone-marrow,  and  especially  of  those  which  he  calls  endosteal  cells,  an 
essential  change. 

In  the  stage  of  recovery,  the  temporary  calcification  of  the  cartilage  and 
the  changes  of  the  osteoid  tissue  to  hard,  solid  bone,  i.  e.,  eburnation  takes 
place. 

In  severe  rickets,  rather  characteristic  changes  of  the  soft  parts  are  also 
found  and  especially  in  the  striated  as  well  as  in  the  unstriated  muscle 
tissue.  These  consist  in  the  development  of  slender  immature  fibres, 
with  increased  nucleation  and  in  the  modification  of  the  longitudinal  stria- 
tions.  They  are  interpreted  as  specific  disturbances  of  nutrition  of  a  retro- 
grade character. 

The  liver  and  spleen  are  often  enlarged,  due  to  hyperplasia  of  pulp  and 
follicle.  The  lymphoid  tissue  throughout  the  body  is  markedly  swollen. 
The  brain  is  enlarged  as  though  swollen. 

All  these  lesions  bring  about  the  characteristic  habitus  and  picture  of 
rickets;  the  large  head,  the  short  rounded  chest,  the  pendulous  abdomen, 
and  the  short  plump  extremities. 

Chemical  Findings. — In  rickets  the  osseus  tissue  is  extremely  poor  in 
mineral  components  and  especially  in  calcium  and  phosphorous.  The  soft 
parts  are  less  affected.  The  magnesium  salts  are  reduced  absolutely  but 
increased  relatively.  The  ash  of  the  dry  tissue  of  the  ribs  and  vertebra  may 
be  reduced  from  sixty  per  cent,  to  as  low  as  twenty  per  cent.  The  swelling  of 
the  cartilage  is  probably  caused  by  the  loss  of  lime  salts,  since  the  Ca-ions 
inhibit  the  process  of  water  absorption.  This  plays,  however,  but  a  minor 
part  in  the  increase  of  mass.  It  should  be  noted  that  the  insufficient  calci- 
fication of  the  bony  skeleton  in  rickets  corresponds  to  a  reduced  calcium 
retention  throughout  the  body.  The  loss  of  salts  in  the  rickitic  infant  may 
occasionally  cause  a  negative  calcium  balance,  which  involves  an  increased 
calcium  requirement  during  recovery — a  fact  which  can  be  proved  by 
metabolism  experiments.  Up  to  the  present  time,  no  further  findings  of 
particular  patliogenetic  importance  have  been  demonstrated. 

The  calcium  content  of  the  blood  in  rickitic  infants  is  subject  to  wider 
variations  than  in  non-rickitic  infants,  both  above  and  below  the  normal 
( Aschenheim) .  Since  this  figure  consists  of  three  quotients,  that  is,  the 
true  blood  calcium,  the  calcium  of  the  food  metabolism  and  the  waste 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  193 

calcium,  the  interpretation  of  this  variation  is  not  too  clear.  Negative 
balances  of  alkalies,  chlorides,  sulphur,  and  magnesia  are  not  characteristic 
of  the  mineral  metabolism  in  rickets,  which  explains  the  difference  from 
infant  atrophy  and  clears  up  their  relation  to  tetany. 

Pathogenesis. — The  anatomic  study  has  shown  that  the  basic  cause  of 
the  characteristic  findings  in  the  skeleton  is  due  to  the  failure  of  proper 
mineralization  of  cartilage  and  bone.  With  the  recognition  of  this  fact,  a 
further  study  of  the  pathogenicity  of  the  disease  was  given  a  definite  basis 
for  promising  inquiry,  but  beyond  it  positive  knowledge  does  not  extend. 

Why  do  the  newly  developed  parts  of  the  skeleton  take  up  little  or  no 
inorganic  salts  from  the  beginning  of  the  disease?  Three  plausible  possi- 
bilities present  themselves: 

1.  The  intake  of  the  mineral  constituents  of  the  body  may  be  quanti- 
tatively insufficient,  or  the  form  in  which  they  appear  in  the  blood  may  be 
unsuitable.    This  might  be  due  either  to  a  scarcity  of  calcium  in  the  food- 
stuffs, or  to  a  relative  inadequacy  of  the  calcium  digestion  and  absorption. 
Proceeding  upon  this  theory,  researches,  into  which  obvious  factors  of 
error  entered,  were  presented  to  sustain  the  surprising  view  that  the  mother's 
milk  could  not  long  fulfill  the  demand  for  lime  salts  put  upon  it  by  the 
growing  organism  of  the  child.     This  hypothesis,  repeatedly  advanced,  but 
unsupported  by  pediatric  authority,  may  be  dismissed.     Confirmed  experi- 
ments offer  no  proof  whatever  of  a  primary  disturbance  in  the  calcium  or 
in  any  other  specific  phase  of  metabolism. 

The  premises  upon  which  this  teaching  rests  are  not  tenable.  Bru- 
bacher,  Stoltzner,  Cronheim  and  Mueller,  contradicting  the  findings  of 
other  writers,  show  that  the  alleged  reduction  of  the  calcium  and  other 
salts  does  not  manifest  itself  in  the  soft  parts  of  the  body  as  it  does  in  the 
bony  tissue. 

Further,  the  consensus  of  judgment  of  numerous  podiatrists  indicates 
that  neither  an  increase  of  the  calcium  intake,  nor  an  improvement  of 
calcium  absorption  will  successfully  serve  as  either  a  prophylactic  or  a 
therapeutic  measure  in  acute  rickets.  The  form  of  disease  induced,  in 
growing  animals,  by  a  calcium-free  diet  differs  from  rickets.5  This  is  both 
histologically  and  biochemically  true.  Under  such  calcium  starvation,  an 
extract  of  the  muscular,  cartilaginous  and  bony  tissues  dissociates  and 
takes  up  the  calcium  ion  from  a  neutral  solution  of  the  calcium  salts  with 
avidity.  This  is  not  observed  to  so  marked  a  degree  with  rickitic  material. 

2.  An  intrinsic  disease  of  the  growing  skeleton  itself  may  interfere  with 
its  proper  mineralization.    This  is  not  to  say,  of  course,  that  rickets  is  an 
affection  limited  to  the  skeletal  parts;  but  rather  that  an  abnormality 
occasionally  hindering  the  mineralization  of  the  skeleton  might  be  con- 
sidered analogous  to  such  other  disturbances,  in  other  systemic  organs,  as 
myo-dystrophia,  anemia,  etc. 

Such  prominent  pathologists  as  Pommer  and  von  Recklinghausen  do 
not  concede,  as  Kassowitz  supposes,  that  actual  inflammatory  processes 
play  any  part  in  preventing  calcification.  Schmorl  opposes  the  statement 

5  Stoltzner,  Schmorl. 
13 


194  TEXT-BOOK  OF  PEDIATRICS 

of  Stoltzner  who  holds-  that  the  fundamental  fact  in  rickets  is  an  inhibi- 
tion of  development ;  that  the  normal  metaplasia,  microchemically  demon- 
strable, which  matures  the  osteoid  tissue  as  a  calcium  absorber,  is  absent  in 
rickets.  Similarly,  the  recent  experiments  of  Adele  Hartmann  show  that 
pieces  of  rickitic  cartilage  placed  in  the  abdominal  cavity  of  the  rabbit  do 
not  retard  calcification  any  more  markedly  than  do  non-rickitic  tissues 
similarly  introduced.  According  to  these  researches,  the  tissues  of  the 
rickitic  patient  do  not  lack  the  power  of  calcium  absorption.  They  tend, 
rather,  to  show  that  there  is,  in  the  rickitic  organism,  a  functional  limitation 
upon  the  mineral  metabolism. 

3.  This  view  is  embodied  in  the  third  .of  this  group  of  hypotheses,  which 
postulates  a  continuous  decalcification  and  a  consequent  failure  to  store  the 
lime  salts  as  a  result  of  an  abnormal  acidity  of  the  body  fluids.  Aside  from 
the  fact  that  the  condition  is  one,  not  only  or  merely  of  decalcification,  but 
of  actual  demineralization,  this  theory  violates  Stoltzner 's  finding  of  a  nor- 
mal reaction  of  the  blood  serum  in  rickets. 

As  a  result  of  the  discovery  of  primary,  irritative,  systemic,  changes  in 
the  bone-marrow,  Marfan  has  recently  come  to  the  conclusion  that  these 
processes  affect  the  function  of  the  osteoblasts  arising  from  the  bone-mar- 
row and  thus  hinder  calcification.  The  proposal  of  this  theory  of  the 
myelogenous  nature  of  the  disease,  in  spite  of  Zeigler's  teaching  as  to  the 
functional  independence  of  the  blood-forming  and  the  bone-forming  marrow 
seems  especially  noteworthy  in  view  of  the  relation  of  rickets  to  scurvy  and 
to  von  Jaksch's  anemia.  Ribbert  finds  a  toxogenous  necrosis  of  the  carti- 
lage cells  in  rickets. 

Other  hypotheses  and,  in  particular,  that  which  lays  the  cause  of  the 
disease  to  the  absence  of  an  internal  secretion  of  certain  glands,  as  the 
thymus,  thyroid,  suprarenal  body  or  liver,  lack,  at  present,  reliable  positive 
support.  Erdheim  claims  to  have  produced  rickitic  bone  changes  in  rats  by 
the  excision  of  the  parathyroids.  Animals  in  which  rickets  occurs  spon- 
taneously are  said  to  have  enlarged  parathyroids. 

Occurrence  and  Etiology. — It  is  difficult  to  form  any  statistical  estimate 
of  the  frequency  of  rickets  because  the  subjective  signs  of  it  so  closely 
simulate  physiologic  conditions.  Systematic  reports  of  anatomic  findings 
in  the  large  mass  of  unselected  material  coming  to  autopsy  should  be 
accepted,  rather  than  the  extraordinarily  variable  and  but  crudely  oriented 
results  of  clinical  examination.  The  following  table  is  computed  from  the 
autopsy  reports  of  Schmorl.  This  indicates  that  the  disease  never  appears 
before  the  middle  of  the  second  month  and  only  occasionally  after  the 
end  of  the  second  year,  and  that  it  affects  almost  every  child  between  these 
two  periods. 

It  should  be  noted  that  this  table  includes  children  who  have  died  at  an 
early  age;  and  that  they  were  probably,  in  large  part,  of  the  poorer  classes. 
It  is  also  to  be  observed  that  rickets  is  exceptionally  common  in  the  material 
presented  by  this  author. 

It  is  the  experience  of  the  author  that  premature  infants  are  not  affected 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS 


195 


with  rickets,  at  the  same  actual  age  as  other  infants,  but  at  periods  of 
relative  development. 

In  certain  families  the  frequency  and  severity  of  rickets  appear  to  be 
influenced  by  hereditary  factors.  Not  only  does  the  disease  appear  even 
under  favorable  circumstances  in  the  children  of  rickitic  parents,  but  it  has 
been  noted,  selectively,  in  the  progeny  by  different  fathers  of  a  mother  who 
was  rickitic.  The  heredity  of  a  structural  tendency  to  rickets  is  doubtful. 

The  occurrence  of  the  disease  is  influenced  by  the  method  of  feeding. 
Severe  forms  are  very  much  more  common  in  overfed  and  artificially-fed 
babies  than  in  the  breast-fed. 

It  cannot  be  said  that  other  diseases,  e,  g.,  disturbances  of  nutrition  and 
infections,  determine  the  appearance  of  rickets.  In  fact  the  diseases  which 

TABLE  II. 
RICKITIC  AND  NON-RICKITIC  CHILDREN  AT  VARIOUS  AGE  PERIODS. 


Age  in  months  

0-1 

1-3 

3-6 

6-9 

9-12 

12-18 

18-24 

24-36 

36-48 

Non-rickitic  children  .  . 

100 

39.4 

3.0 

6.0 

2.7 

1.7 

9.1 

12.3 

29.4 

Early    rickets,    micro- 
scopically recognized.  .  . 

48.5 

55.8 

32.0 

9.2 

6.8 

6.1 

Acute    rickets    recog- 
nized    macroscopically 
and  microscopically.   .  . 

21.1 

20.6 

43.2 

60.0 

54.2 

30.3 

20.1 

5.9 

Convalescing  cases  .... 

20.6 

18.8 

26.7 

25.4 

33.3 

21.5 

8.8 

Recovered  cases      .... 

1.4 

11.9 

21.2 

46.1 

55.9 

limit  growth  seem  rather  to  counteract  the  development  of  rickitic  changes. 
Atrophic  infants,  for  instance,  are  never  severely  rickitic.  Nevertheless, 
the  signs  of  rickets  are  not  commonly  seen  in  naturally-fed  or  in  suitably, 
if  artificially-fed  children  who  are  scrupuously  cared  for  and  are  of  normal  or 
supernormal  development  and  have  shown  no  evidences  of  nutritional 
disturbance.  If  fat  infants,  who  are  frequently  ill  and  of  consequently 
lowered  resistance,  seem  to  be  especially  predisposed  to  rickets,  it  is  possible 
that  their  diminished  bodily  activity  plays  a  more  or  less  important  part. 
In  general,  the  children  of  the  well-to-do  are  affected  as  often,  but  certainly 
not  so  severely,  as  the  children  of  the  poor. 

Furthermore,  rickets,  as  a  disease  of  the  masses,  is  influenced  by  modes 
of  living.  All  those  influences  of  domestication  and  civilization  which 
disturb  the  natural  and  primitive  habits  of  life;  which  tend  to  close  and 
crowded  housing  of  the  poor;  which  favor  indoor  and  sedentary  occupations, 
and  permit  but  limited  and  unbalanced  physical  exercise,  favor  the  occur- 
rence and  development  of  rickets.6 

The  most  potent  factor  resulting  from  domestication,  to  which  Kassowitz 
calls  particular  attention,  is  the  element  of  respiratory  injury.  It  is  held 
responsible  for  the  high  prevalence  of  rickitic  disease  in  densely  popu- 
lated tenements. 

6  Von  Hansemanri,  Neumann. 


196  TEXT-BOOK  OF  PEDIATRICS 

Findlery's  observations,  of  a  strictly  experimental  order,  show  that  in 
forms  of  disease  identical  with,  or  closely  resembling  human  rickets,  pro- 
duced or  spontaneously  incurred  in  young  animals  kept  in  confinement, 
the  toxic,  infections  or  nutritive  injuries  present  were  less  directly  causative 
of  the  disorder  than  was  the  enforced  change  from  a  natural  mode  of  living 
to  existence  in  close,  dark  cages. 

Numerous  historical  facts  sustain  this  teaching.  The  geographic  and 
racial  distribution  of  rickets  is  in  accord  with  it.  Its  gradual  increase  in 
frequency  since  the  seventeenth  century;  its  present  maximal  dissemination 
through  all  the  countries  of  the  temperate  zone;  its  relative  scarcity,  with- 
out evidence  of  racial  immunity,  in  the  arctic  circle,  in  the  tropics,  at  high 
altitudes  and  in  all  sparsely  populated  regions,  are  all  significant.  Its 
prevalence  or  greater  severity  in  the  winter  and  spring  months,  and  in  the 
densely  peopled  parts  of  large  cities;  and,  finally,  the  important  influence 
of  fresh  air,  natural  feeding  and  intelligent  management  in  the  treatment  of 
the  disease,  testify  in  support  of  such  a  rational  theory. 

A  factor  recently  added  to  the  etiology  of  rickets  and  brought  into  much 
prominence  is  the  question  of  the  lack  of  certain  accessory  food  substances 
(vitamins) .  While  the  theories  about  this  factor  have  formerly  been  rather 
vague,  American  observers  in  animal  experiments  and  pediatricians  in  the 
central  empires,  during  the  food  shortage,  caused  by  the  blockade  have  added 
considerable  research  to  this  view.  A  fat  soluble  vitamin  (fat  soluble  A) 
is  said  to  prevent  rickets.  It  occurs  in  various  foods  in  varying  degree,  as 
follows:  whole  milk,  cod-liver  oil,  butter,  egg  yolk,  red  meat,  and  to  some 
extent  in  fresh  vegetables.  -It  is  supposed  to  originate  in  green  vegetables 
and  germ  cells  of  cereals.  It  is  fairly  thermostable.  It  does  not  originate 
in  the  animal  body.  It  is  well  to  await  further  research  upon  this  large 
question  before  dropping  further  study  of  the  etiology  of  rickets. 

Clinical  observation  of  the  disease  indicates  that  two  important  factors 
enter  into  its  pathogenesis;  the  first,  a  latent  predisposition  dependent  upon 
a  specific  heredity,  a  rickitic  diathesis  or  constitution,  as  it  were,  of  the 
nature  of  which  we  are  profoundly  ignorant;  and  second,  the  infliction  of 
certain  nutritive  injuries,  arising  from  numberless  causes  and  occurrent 
perhaps  even  in  intra-uterine  life. 

CLINICAL  SYMPTOMS  AND  THEIR  ORIGIN 
SKELETAL  MANIFESTATIONS 

First  Group:       Phenomena  of  delayed  bone  development;  hypogenesis  ossium. 
Second  Group:  Phenomena  of  bone  softening,  osteomalacia. 

Third  Group:     Phenomena  of  excessive  new  formation  of  bony  tissue;  osteoid  hyper- 
plasia  and  development  of  osteophytes. 

In  thz  first,  group  of  symptoms,  the  delayed  growth  may  affect  any  or  all 
parts  of  the  skeleton;  it  may  cause  a  large  number  of  abnormal  conditions 
and  may  particularly  disturb  the  symmetrical  proportions  and  measure- 
ments of  the  body.  The  slow  growth  of  the  facial  bones  gives  the  cranium 
the  appearance  of  being  unduly  large.  Disease  of  the  vertebral  column  and 
of  the  long  bones  affects  the  growth  in  height.  Rickitic  children  are  shorter 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS 


197 


than  others,  even  if  no  actual  distortion  of  the  bones  occurs.  During  the 
acute  stage,  and  even  later,  there  may  be  long  continued  and  complete 
arrest  of  growth  and  consequent  dwarfing.  The  latter  result  is  especially 
common  in  cases  which  appear  late  and  persist  for  a  long  period.  This 
retarded  growth  and  the  accompanying  flaccidity  of  the  muscular  tissues, 
with  the  painful  periosteal  points  at  the  insertion  of  the  muscles,  is  apt  to 
delay  the  acquirement  of  the  static  and  dynamic  functions  of  the  child,  as 


FIG.  45.  — Three  and  one-half-year-old  boy  with  rickets.  Charac- 
teristic sitting  posture  with  legs  doubled  under  the  body  and  arms 
supporting  the  spine.  Slight  deformity  of  the  head,  thorax  and 
limbs 

in  the  raising  of  the  body,  in  sitting,  crawling,  standing  and  walking  and  in 
the  general  mobility  of  the  extremities.  When  the  disease  appears  late  in 
infancy  or  in  childhood,  the  ability  to  walk  may  be  lost.  When  a  rickitic 
child  is  lifted,  it  does  not  attempt  to  stand,  but  keeps  its  legs  drawn  up. 
In  sitting,  the  legs  are  doubled  under  the  body  and  the  arms  are  used  to  sup- 
port t"he  spine.  The  impaired  ossification  of  the  flat  cranial  bones  is  shown 
in  their  abnormal  width  and  in  the  delayed  closure  of  the  sutures  and 
fontanelles.  The  anterior  fontanelle  increases  in  size  for  a  time  and  occa- 
sionally remains  open,  or  membranous,  until  the  third  year.  The  retarded 


198 


TEXT-BOOK  OF  PEDIATRICS 


development  is  especially  noticeable  in  the  teeth.  Both  the  beginning  and 
the  end  of  the  first  dentition  may  be  delayed  for  as  long  as  eighteen  months, 
so  that  the  first  teeth  appear  at  two  years  and  the  last  as  late  as  three  and 
a  half  years.  The  individual  teeth  appear  at  unusually  long  intervals; 
erupt  asymmetrically  and  in  atypical  order.  Particularly  in  the  upper  jaw, 
they  are  frequently  small,  soft,  easily  broken  and  discolored  by  caries,  to 
which  they  are  peculiarly  liable.  They  are  often  frightfully  misshaped  and 
foreshortened.  There  is  occasionally  an  excessive  formation  of  enamel. 
The  temporary  teeth  show  striped  or  circular  erosions  at  neck  and  root. 
The  permanent  teeth,  the  germs  of  which  are  also  affected,  show  these 


FIG.  46.— Thigh  and  leg  of  a  three  and  one-half-year-old 
child  with  severe  rickets.  Infraction  and  characteristic 
cupping  at  the  diaphyses. 

erosions  at  the  crown.  Examination  with  the  Roentgen  rays,  reveals  the 
small  centres  of  ossification  and  the  abnormal  transparency  of  the  bone 
tissue  throughout  the  entire  skeleton,  but  especially  in  the  wrist  and  in 
certain  of  the  long  bones.  (See  Characteristic  Roentgenogram,  Fig.  46.) 

In  the  second  group,  an  important  early  symptom  which  may  exist, 
temporarily,  alone  and  may  be  continuously  present,  is  the  so-called  cranio- 
tabes.  Palpation  over  the  occipital  bone  and  over  the  posterior  portions  of 
the  parietal  bones  discovers  circumscribed  areas  of  softened  bone  which  can 
be  depressed  They  are  rarely  confluent  and  are  about  the  size  of  a  small 
coin.  The  sensation  received  upon  pressing  one  of  these  areas  may  be 
compared  to  that  which  is  given  in  pressing  upon  parchment,  or  over  the 
convex  surface  of  an  old  stiff  felt  hat. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS 


199 


The  continued  pressure  of  the  body-weight  and  the  strain  of  the  constant 
muscle  tonus  upon  the  persistently  soft  bones  will  inevitably  produce 
characteristic  changes  in  the  way  of  deformities  and  decurvations  in  the 
skeletal  framework.  Similarly,  external  violence  will  cause  breaks  of  con- 
tinuity much  more  readily  than  in  the  normal  structure.  Since  the  bony 
substance  is  elastic,  it  will  bend  rather  than  actually  break.  Even  when 
true  fractures  do  occur  the  ends  usually  remain  in  apposition  by  virtue  of  the 
thickened  periosteum.  Fractures  and  infractions  are  therefore  easily  mis- 
taken for  deformities.  True  rickitic  bone  decurvations  usually  involve  a 
pathologic  excess  of  the  physiologic  curves.  Space  will  not  permit  a  more 
detailed  description  of  the  varying  conditions  and  possible  combinations 
which  these  deformities  may  present. 
They  are  of  interest  chiefly  from  the 
orthopedic  standpoint.  An  attempt 
has  been  made  to  present  pictures  of 
the  most  common  and  most  serious 
deformities.  (See  Figures  47  to  52.) 
Special  attention  is  called  to  the  fol- 
lowing types :  The  head  shows  enlarge- 
ment of  the  cranium,  with  softening 
of  the  edges  of  the  bones.  The  lower 
jaw  is  shortened  sagittally  (trapezi- 
form)  and  the  upper  jaw  is  narrowed 
(lyraform).  The  lower  alveolar  proc- 
ess is  directed  inward  and  the  upper 
ib  directed  outward,  with  such  conse- 
quences to  the  teeth  as  transverse 
placement  of  the  upper  incisors  and 
projection  of  the  lower.  The  occluding 
surfaces  are  but  poorly  covered  by 
enamel;  the  palatal  arch  is  high;  the 
zygoma  is  sharply  bent. 

The  spinal  column  is  kyphotic, 
with  dextroconvex,  bow-like  scolioses  in  the  lumbar  and  thoracic  regions, 
and  with  compensating  curves  in  other  parts.  In  the  production  of  these 
deformities  the  flaccidity  of  the  muscles  and  the  manner  of  carrying  the 
child  have  important  influence. 

The  thoracic  changes  consist  in  a  flattening  and  inversion  of  the  lateral 
walls,  especially  from  the  third  rib  down  to  Harrison 's  groove  at  the  level 
of  the  ensiform  process  of  the  sternum.  Below  this  the  costal  arch  is  rolled 
outward;  its  lower  margin  is  widened,  while  the  upper  or  cervical  rim  is 
narrowed.  The  lower  segments  of  the  sternum  and  the  costal  cartilages 
are  pushed  outward  as  a  result  of  the  increased  negative  pressure  in  inspir- 
ation, the  direct  action  of  the  respiratory  musculature  on  the  flexible  bony 
wall,  and  the  distention  of  the  abdomen  combining  to  cause  chicken- 
breast,  or  a  heart-shaped  cross  section  of  the  thorax. 

The  pubic  angle  is  spread,  the  promontory  is  pushed  forward  and  the 


FIG.  47. — Two-year-old    child  showing  rickitic 
deformity  of  cranium  and  thorax. 


200 


TEXT-BOOK  OF  PEDIATRICS 


conjugates  are  shortened,  producing  a  flat  pelvis.  The  neck  of  the  femur 
is  horizontal  (coxa  vara)  to  the  shaft  of  the  bone,  which  curves  with  convex- 
ity forward  and  outward.  The  tibia  its  curved  forward  in  its  lower  third 
(Saber  tibia).  Genu  valgum  or  genu  varam  may  be  either  unilateral,  or 
symmetrically  bilateral,  or  the  contrary.  Pes  valgus  occurs. 

The  upper  extremities  are  usually  less  deformed  than  the  lower.    Multi- 
ple infractions  of  the  clavicles,  ribs,  radius  and  femur  are  common. 

The  Third  Group. — The  picture  of  the  rickitic  deformities  of  the  skeletal 
framework  is  finally  completed  by  the  enlargments  and  protuberances  upon 

the  flat  bones  which  are  incident 
to  the  excessive  formation  of 
new  bone. 

Rounded  deposits  of  bone, 
at  first  fairly  circumscribed,  are 
often  formed  symmetrically  up- 
on the  frontal  and  parietal  emi- 
nences and,  more  rarely,  at 
the  edges  of  the  cranial  bones. 
Between  these,  the  sagittal  and 
coronal  sutures  are  depressed, 
forming  the  so-called  saddle  or 
cross-bun  head.  Such  protu- 
berances, together  with  a  flat- 
tening of  the  occiput,  give  the 
enlarged  head  a  quadrilateral 
form,  the  so-called  square  head, 
or  caput  quadratum. 

Upon  the  outer  and  more  of- 
ten upon  the  inner  surfaces  of 
the  costochondral  articulations 
large  twin  nodules  appear.  The 
line  of  nodules  forms  a  divergent 
arc,  which  is  called  the  rickitic 
rosary. 

The  epiphyses  of  the  long 
bones,  particularly  at  the  wrist, 
are  the  seat  of  nodular  enlarge- 
ments. As  compared  with  these,  the  thickening  and  rounding  out  of  the 
diaphyses  is  usually  less  noticeable.  The  bones  of  the  wrist,  as  well  as 
the  phalanges,  are  enlarged  at  intervals,  presenting  the  appearance  of  a 
string  of  beads.  The  severe  decurvations  of  the  bones  and  particularly 
the  large  calli  forming  over  slowly  healing  infractions  may  be  mistaken 
for  rickitic  osteophytes.  While  the  decurvations,  infractions  and  enlarge- 
ments of  the  various  parts  of  the  skeleton  may  present  extreme  and  fan- 
tastic malformations  in  severe  or  neglected  cases,  they  are  ordinarily  not 
excessive  and  are  in  part  concealed  by  the  fatty  panniculus.  They  may 
even  be  entirely  absent.  The  most  common  and  noticeable  among  them 


FIG.  48. — Three-year-old  boy  with  high  grade  rickitic 
deformities  of  the  extremities  cranium  and  tho- 
racic skeleton. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  201 

are  the  rosary,  the  disturbances  of  dentition,  the  large  fontanelles  with  soft 
edges,  and  the  nodular  enlargements  of  the  epiphyses  at  the  wrist. 

The  order  of  appearance  of  the  skeletal  changes  is  synchronous  with  the 
normal  periods  of  rapid  growth  of  the  several  bones  (Vierordt).  This 
development  occurs  earlier  in  the  cranium  and  the  thorax  than  in  the  ex- 
tremities. Therefore,  the  craniotabes  and  the  rosary  are  among  the  first 
symptoms  to  appear.  The  depression  of  the  walls  of  the  thorax  and  the 
enlargement  of  the  fontanelle  are  noticed  later.  The  square  head  (caput 
quadratum),  the  kyphosis,  and  the  changes  in  the  extremities  follow  only  at 
the  end  of  the  first  year.  The  grosser  and  more  permanent  deformities  of  the 
limbs  develop  quite  late  and  particularly,  of  course,  when  they  are  func- 
tionally employed,  as  in  sitting,  creeping  and  standing.  Deformities  of  the 
thigh,  however,  have  been  found  even  in  infants  who  were  still  in  the 
cradle.  If  rickets  occurs  later  in  life  craniotabes  does  not  appear. 

Most  of  the  clinically  recognized  changes  and  disturbances  of  function 
attendant  upon  rickets,  appearing  in  other  organs,  may  be  generally  inter- 
preted as  complications  or  sequelae  of  the  disease  without  compromising  the 
conception  that  rickets  is  a  general  dyscrasia.  (Glisson,  1650.) 

A  direct  mechanical  relation  doubtless  exists  between  the  thoracic 
deformity  and  certain  respiratory  disturbances.  The  flexibility  of  the  bony 
chest  wall  limits  the  excursions  of  the  diaphragm;  this,  in  turn,  impairs  the 
ventilation  of  the  lung  and  lessens,  again,  the  respiratory  interchange  of 
gases.  The  contraction  of  the  diaphragm,  instead  of  promoting  the  proper 
expansion  of  the  lungs,  draws  in  the  lateral  thoracic  walls  and  even  the 
sternum.  This  results  in  dyspnoea,  tachypnoea,  cyanosis,  expansion  of  the 
nares  and  diseases  of  the  respiratory  tract.  The  relation  between  the  di- 
minished agility  with  the  increased  irritability  of  the  rickitic  patient  and  the 
pain  developed  upon  active  and  passive  motion  and  due  to  the  disease  of  the 
skeletal  framework  and  musculature,  is  quite  apparent.  In  the  acute 
stage  of  the  disease,  fear,  timidity,  irritability,  and  distrust  are  depicted 
upon  the  infant 's  face.  The  child  is  afraid  of  everyone  who  approaches  the 
bed  and  protests  either  by  cries  or  by  peculiar  and  vigorous  motions  of  the 
hand,  against  being  touched. 

Another  group  of  possible  complications  includes  anemia,  marked 
enlargement  of  the  liver  and  spleen  and  general  hyperplasia  and  induration 
of  lymph  nodes,  tonsils,  etc.  The  anemia  is  characterized  by  pallor,  oligo- 
cytosis,  oligochromemia,  poikilocytosis,  erythrocytosis,  lymphocytosis,  and 
increase  of  the  mononuclear  cells.  The  liver  and  spleen  are  often  displaced 
downward  by  the  thoracic  deformity,  a  tendency  which  should  not  be  mis- 
taken for  actual  enlargement.  It  is  a  widely  accepted  view  that  these 
general  symptoms  are  proportional  to  the  severity  of  the  skeletal  disease  and 
are  relational  to  the  lesions  of  the  bone-marrow,  whether  primarily  so,  as 
Marfan  holds,  or  in  a  secondary  way.  (See  the  pathogenesis  of  von  Jaksch's 
anemia,  etc.) 

Rickitic  myopathy,  to  which  reference  has  already  been  made,  is  almost 
always  present.  It  manifests  itself  in  general  weakness  and  lassitude,  mus- 
cular atony,  atrophy  and  flaccidity,  and  in  an  abnormal  mobility  of  the 


202  TEXT-BOOK  OF  PEDIATRICS 

joints.  It  is  probably  primary  to  a  degree.  The  tempting  hypothesis  that 
this  myopathy  is  merely  a  sequel  to  severe  disease  of  the  skeleton  and  is 
conservative,  since  it  relieves  the  strain  upon  the  bony  framework,  is  sup- 
ported neither  by  the  structural  quality  of  these  muscular  changes  (Bing, 
Martins)  nor  by  the  facts  of  their  distribution.  Nor  is  such  a  hypothesis 
compatible  with  the  involvement  of  the  entire  unstriated  muscular  system, 
frequently  observed  and  indicated  by  an  abnormal  dilatation  of  the  heart 
and  the  arteries,  by  gastro-intestinal  atony,  obstipation  and  tympany. 
Furthermore,  other  soft  parts,  such  as  the  skin,  the  panniculus,  etc.,  are  no 
less  flaccid  than  the  muscular  tissues. 

The  impaired  mobility  and  delayed  development  of  the  rickitic  child 
readily  lead  to  a  delay  in  its  social  and  mental  development,  evidenced  by  a 
low  grade  of  intelligence,  imagination,  and  a  limited  vocabulary.  Con- 


FIG.  49.— Three-year-old  girl  with  rickitic  cross-bun 
head,  protrusion  of  the  tuberosities  and  defects  of  the 
temporary  teeth. 

versely,  any  previously  existing  marked  degree  of  feeble-mindedness  which 
tends  to  confine  the  child  to  its  bed.  may  be  a  cause  of  increased  severity  in 
the  course  of  rickets. 

Spasmophilia,  often  combined  with  and  closely  relational  to  rickets, 
probably  belongs  to  the  group  of  manifestations  coordinate  with  the  skele- 
tal disease. 

The  onset  of  rickets  is  usually  announced  by  a  number  of  premonitory 
symptoms,  the  nature  of  which  Is  not  clear.  The  child  becomes  listless, 
restless,  peevish.  It  bores  its  head  deeply  into  the  pillow  and  wears  off  all 
the  hair  over  the  occiput  by  a  continual  to  and  fro  movement.  During 
sleep  a  profuse,  clammy,  acid  perspiration,  especially  about  the  head, 
appears,  accompanied  by  numerous  sudamina.  Transient  erythemata  and 
pressure  spots  are  further  signs  of  vasomotor  disturbance.  The  abdomen 
becomes  distended.  The  urine  has  an  unusually  sharp,  penetrating  odor. 
The  earlier  evidences  of  disease  in  the  skeleton  and  the  musculature  are 
noticed  only  after  days  or  weeks. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS 


203 


COURSE,  COMPLICATIONS,  TERMINATION 

The  first  skeletal  symptoms,  craniotabes,  kyphosis  and  the  rosary  may 
develop  rapidly  to  a  serious  degree.  Otherwise  the  course  of  the  disease  is 
chronic  and  often  remittent,  extending  from  a  period  of  months  up  to  two 
years.  In  every  case  that  survives,  spontaneous  recovery  eventually  obtains. 
The  beginning  of  recovery  is  heralded  by  the  disappearance  of  general 
symptoms  and  by  the  evidences  of  functional  progress,  as  in  attempts  at 
standing,  uncertain  efforts  to  walk,  etc.  The  calcification  of  the  skeleton 
becomes  complete  in  recovered  cases.  In  the  course  of  years,  deformities 
and  especially  the  decurvations  of  the  long  bones  are  often  overcome  to  a 
surprising  degree  in  the  process  of 
growth.  Dwarfism,  hump-back, 
scolioses  and  other  malformities, 
on  the  other  hand,  may  persist 
throughout  life. 

Rickets  is  never  a  direct  cause 
of  death,  but  it  is  very  often  a 
contributory  factor.  The  mortal- 
ity of  rickitics  is  especially  great 
under  hospital  conditions.  Out- 
side of  hospitals,  the  death-rate  is 
greatest  among  the  poor.  The 
most  common  and  serious  com- 
plications, induced  by  intercur- 
rent  infections,  are  bronchial 
catarrh,  capillary  bronchitis,  with 
or  without  broncho-pneumonia, 
severe  forms  of  spasmophilia  with 
eclampsia  and  laryngospasm,  and 
chronic  enteritis  of  long  duration. 
The  gastro-intestinai  infections 
follow  milk  feeding  injuries  and 
are  characterized  by  foul  smelling, 
watery  stools  and  pseudo-ascites,  in  the  course  of  which  the  nutrition  is 
reduced  to  the  lowest  stage.  Other  complicating  events,  as  diastasis  of 
the  recti,  hernia  and  nystagmus,  are  of  less  consequence.  The  distorted 
respiratory  mechanism,  involving  the  decurvation  of  the  thoracic  walls,  the 
continued  decubitus  and  the  flaccid  and  distended  abdomen  are  invitations 
to  pulmonary  disorders. 

DIFFERENTIAL  DIAGNOSIS 

Even  with  the  appearance  of  a  number  of  characteristic  skeletal  and 
general  symptoms  which  seem  to  insure  a  definite  and  reliable  diagnosis  of 
rickets,  certain  errors  are  still  common.  In  order  to  avoid  them  it  should 
be  remembered  that  congenital  forms  of  disease,  of  whatsoever  type,  are 
never  of  rickitic  nature. 

Certain  structural  imperfections,  such  as  the  physiologic  decurvation  of 


FIG.  oO.  — Two-year-old  child  with  high  grade  rickitic 
deformities  especially  of  the  extremities  and  thorax. 


204 


TEXT-BOOK  OF  PEDIATRICS 


the  infant  leg,  are  sometimes  mistaken  for  symptoms  of  rickets.  "Fetal 
rickets"  is  a  misnomer  and  under  this  head  osteogemsis  imperfecta,  in 
which  the  lack  of  development  of  the  cranial  bones  simulates  craniotabes 
is  often  included.  The  soft  bone  areas  in  this  condition  differ  from  cranio- 
tabes in  that  they  are  situated  in  the  temporal  bone  or  near  the  sagittal 
suture,  and  not  in  the  occiput.  The  fontanelles  are  sharply  circumscribed 
by  hard  bone.  The  deficiency  gradually  disappears  during  the  period 
within  which  rickitic  craniotabes  makes  its  appearance. 

Congenital  myxedema  and  mongoloid  idiocy  have  so  many  symptoms 
strikingly  in  common  with  rickets,  that  many  distressing  diagnostic  errors 

have  been  made.  In  fact,  a  rela- 
tionship between  these  several 
diseases  was,  at  one  time,  ac- 
cepted. The  cretinoid  face,  the 
low  mentality,  the  dryness  of  the 
skin  and  hair,  the  gelatinous  con- 
sistency of  the  subcutaneous  tis- 
sue, the  macroglossia,  the  lower 
trachea  destitute  of  its  thyroid 
covering,  are  indicative  of  myxe- 
dema. The  Mongolian  face  and 
the  purposeless  posturing  indicate 
mongolism.  The  disturbances  of 
motion  in  Oppenheim's  congen- 
ital myatonia,  in  atonic  infantile 
paralysis,  early  infantile  progres- 
sive amyotrophy,  Tay-Sach  's  idi- 
ocy, etc.,  may  be  confused  with 
rickitic  myopathy. 

If  rickets  occurs  in  combina- 
tion with  scurvy,  quite  a  common 
event  and  probably  with  patho- 
genic reason,  the  scurvy  may 
•  remain  concealed.  The  manifes- 
tations of  a  hemorrhagic  diathesis  are  characteristic  of  the  latter.  The 
presence  of  painful  swellings  over  the  ends  of  the  diaphyses,  rather  than 
over  the  epiphyses,  is  not  always  a  reliable  distinction.  Rapid  and  favorable 
therapeutic  results  often  substantiate  the  diagnosis  of  scurvy  in  retrospect. 
To  the  expert,  Roentgenography  gives  positive  evidences. 

In  cases  in  which  severe  endochondral  disturbances  of  ossification,  with 
myopathy,  have  caused  a  form  of  rickitic  paralysis  due  to  pain,  Parrot's 
pseudoparalysis  may  be  suggested. 

Rickitic  kyphosis  may  be  differentiated  from  the  kyphosis  of  Pott's 
disease  by  the  fact  that  in  the  rickitic  the  curvature  is  flatter,  is  not  fixed, 
and  almost  always  disappears  when  the  patient  is  laid  upon  the  abdomen. 

The  pyriform  distension  of  the  hydrocephalic  cranium  may  be  readily 
distinguished  from  the  rickitic  tete  Carre,  or  square  head,  caused  by  the 


FIG.  5L- 


-Rjckjtic  beaded  fingers,  two  and  one-half- 
year-old  girl. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS 


205 


thickening  of  the  frontal  and  parietal  eminences.  The  softness  of  the  rickitic 
cranium,  however  favors,  the  development  of  the  hydrocephalic  enlarge- 
ment ;  while  venticular  dropsy  due  to  vascular  congestion  and  lymphedema 
is  common  in  rickets.  A  true  cerebral  hypertrophy  is  also  supposedly  re- 
lated to  rickets.  Periostea!  processes  on  the  rickitic  cranial  bones  may  be 
mistaken  for  chloromata. 

With  capillary  bronchitis  it  is  often  impossible  to  determine  whether 
small  lobular  pneumonic  foci  are  present.  Pulmonic  dulness  is  some- 
times simulated  by  scolioses,  by  thoracic  deformities  and  by  thickening 
of  the  scapulae. 

Rickets  and  osteomalacia,  ac- 
cording to  recent  researches,  do  not 
differ  in  their  pathology,  but  only 
in  the  period  of  their  occurrence 
and  probably  in  the  matter  of 
cause.  Osteomalacia  affects  the 
mature  bone;  rickets  affects  the 
rapidly  growing  bone.  In  those 
rare  cases  in  which  the  disease 
occurs  between  the  third  year  and 
puberty,  or  in  which  it  continues, 
with  remissions,  throughout  child- 
hood, we  speak  either  of  delayed 
rickets  (rickitis  tarda),  if  the  in- 
creased formation  of  osteophytes, 
the  endochondral  perversions  and 
the  decurvations  (coxa  vara,  genu 
valgum,  pes  planus,  etc.),  are  pres- 
ent,  or  of  juvenile  osteomalacia  if  the 
osteoporosis  is  the  more  prominent. 

Prophylaxis  and  Therapy. — The 
measures  of  prophylaxis  are  those 
used  in  the  treatment.  By  far  the 
most  important  factors  in  preven- 
tion and  care  of  rickets  are  moder- 
ate stimulation  to  bodily  exercise  and  stimulation  of  the  body  as  a  whole. 

First,  we  may  place  the  use  of  active  and  passive  motion,  suited  to  the 
condition  of  the  musculature  and  of  the  skeletal  framework.  Such  exercise 
cannot  be  obtained  if  the  child  lies  continuously  upon  its  back,  wrapped  in 
tight  diapers  infrequently  changed.  A  good  nurse  may  give  the  growing 
child  sufficient  stimulus  for  mild  bodily  exercise.  She  will,  at  least,  give  its 
natural  tendency  to  such  exercise  free  play  while  bathing  and  by  permitting 
the  child  to  lie  naked  on  its  abdomen.  The  arrangement  of  the  bed,  with  a 
moderately  firm  flat  mattress,  proper  mode  of  carrying,  sufficient  play 
and  creeping  all  tend  to  prevent  deformity.  The  child  should  be  not 
encouraged  in  too  frequent  attempts  to  stand  or  walk.  The  Epstein  rocking- 
chair  may  be  used.  (See  page  103.)  In  the  more  severe  osteomalacic  forms, 


FIG.  52. — Five-year-old  girl  with  deformities  of  legs 
following  rickets. 


206  TEXT-BOOK  OF  PEDIATRICS 

which  seldom  occur  save  in  neglected  or  irrationally  treated  cases,  extreme 
caution  is,  of  course,  necessary  on  account  of  the  danger  of  infractions,  even 
while  changing  or  bathing  the  child.  The  use  of  salt  baths  and  of  massage 
doubtless  promotes  active  and  passive  motion.  It  is  well  to  begin  these  pro- 
cedures carefully;  at  first,  with  a  gentle  stroking,  then  by  the  use  of  a  dry 
rub;  later  with  warm  sponges  and  finally  by  tepid  baths  with  salt  content 
increasing  up  to  one  per  cent.,  continued  for  some  ten  minutes;  all  these 
measures  being  constantly  controlled  by  the  so-called  "reaction"  of  the 
skin  (Heubner). 

It  is  also  extremely  important  that  the  little  patients  are  continuously 
in  the  fresh  air  in  sunny,  sheltered  places.  This,  of  course,  is  accom- 
plished very  satisfactorily  by  a  visit  to  localities  of  especially  favorable 
climate.  Children  can  be  protected  against  low  temperature  by  woolen 
clothing.  For  children  in  the  second  and  third  years  who  are  not  severely 
anemic,  high  altitudes  and  mountain  resorts  may  be  considered.  In  the 
city,  every  sunny  hour  during  the  day  should  be  properly  used  in  keeping 
the  child  in  the  yard  or  garden,  or  on  the  veranda  in  an  open  crib  or  baby 
carriage.  During  the  day  the  child  should,  if  possible  sleep  in  the  open  and 
at  night  in  a  freely  ventilated  room.  During  the  summer  months,  carefully 
administered  sun  baths  lasting  at  first  for  only  two  to  three  minuter  may  be 
of  great  value.  Artificial  light  is  said  to  be  very  efficacious  and  is  not  as 
irregular  as  the  sunlight.  Ultra-violet  ray  has  been  suggested. 

The  observation  that  the  treatment  of  rickets  in  hospitals  usually 
accomplishes  but  little,  in  spite  of  the  common  use  of  phosphorus  and  cod- 
liver  oil,  probably  turns  upon  the  fact  that  these  two  determining  factors  of 
fresh  air  and  exercise  have,  until  recently,  received  too  little  consideration. 

As  to  the  dietary  of  rickets,  it  is  at  present  quite  certain  that  no  regime, 
not  even  rationally  conducted  breast  feeding,  is  a  positive  prophylactic 
against  the  disease,  even  in  its  milder  forms.  Further,  it  is  known  that 
every  sort  of  feeding,  including  that  with  breast-milk,  which  encourages 
excessively  rapid  growth,  favors  the  appearance  of  the  disease  and  increases 
its  severity,  suggesting  a  disturbed  relation  between  organic  and  non- 
organic  growth.  It  is  a  generally  accepted  fact  that  a  limited  dietary  but 
slightly  denaturized,  moderate  in  quantity  and  of  sufficiently  varied  quality 
is  the  most  desirable  in  this  condition.  So  that  in  threatened  or  acute 
rickets,  we  should  vary  from  the  rational  methods  of  feeding  for  healthy 
children,  suggested  elsewhere  in  this  work,  only  in  so  far  that  we  may  select 
carefully  prepared  additions  of  soup  and  bread  and  of  various  freshly 
boiled  vegetables  at  an  earlier  date  than  usual.  If  these  additions  are  well 
borne,  which  is  not  invariably  the  case,  they  may  be  given  together  with  a 
limited  quantity  of  milk,  not  exceeding  one  pint  a  day.  Buttermilk  fre- 
quently gives  better  results.  The  reduction  of  the  supply  of  milk,  together 
with  careful  hygienic  care,  is  the  best  method  of  overcoming  anorexia. 

In  chickens  and  animals  that  are  fed  phosphorus,  the  bones  become 
sclerotic.  On  the  strength  of  these  observations,  Wagner  recommended 
phosphorus  in  the  treatment  of  rickets  and  Kassowitz  found  it  very  use- 
ful. These  experiments,  however,  were  made  upon  animals  and  upon 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  207 

non-rickitic  animals  at  that.  The  effect  produced  in  them  was  probably 
the  opposite  of  osteoporosis.  But  this  condition  plays  a  secondary  role 
among  the  phenomena  of  rickets  and  is  one  of  those  manifestations  which 
do  not  suggest  the  etiologic  character  of  the  disease.  From  this  point  of  view, 
therefore,  the  phosphorus  therapy  cannot  be  regarded  as  scientific  or  as  in 
any  way  relational  to  the  cause  of  the  disease  (Stoeltzner). 

This  is  true  of  phosphorus  in  emulsion  of  almond  oil  and  gum  acacia 
as  first  used  by  Kassowitz.  Because  this  emulsion  would  not  keep,  it  was 
replaced  by  the  solution  of  phosphorus  in  cod-liver  oil.  This  mixture 
has  proved  its  value  empirically  but  there  is  much  question  as  to  which  of 
the  two  constituents  is  the  more  effective.  The  customary  prescription  is 
as  follows: 

Oleii  Phosphorati         2.0  (40  minims) 
Oleii  Morrhuse          200.0  (8  ounces) 

The  phosphorated  oil  is  a  one  per  cent,  solution  of  phosphorus  and  the  above 
prescription  gives  one  part  phosphorus  in  10,000  parts  of  the  oil.  Other 
forms  in  which  phosphorus  may  be  prescribed  seem  much  less  active  or 
otherwise  less  useful.  The  "non-purified"  cod-liver  oil  is  recommended. 
It  should  be  protected  from  sunlight  and  other  oxidizing  influences.  The 
dosage  is  four  c.c.  (one  teaspoonful)  twice  daily  and  must  be  kept  up  for 
several  months. 

During  the  period  of  recovery,  the  calcium  and  phosphorus  requirement 
is  naturally  increased.  In  view  of  this  increase,  and  not  because  of  the  older 
view  that  the  rickets  was  caused  by  insufficient  lime  in  the  food,  the  addi- 
tion of  calcium  and  phosphorus  salts  have  been,  recently,  highly  recom- 
mended. Cow's  milk  is  a  food  with  a  high  content  of  these  salts  but  in 
certain  cases  the  fat  obstructs  the  calcium  retention.  The  benefit  of  these 
salts  is  hardly  great  enough  to  pay  their  purchase  price,  especially  if  the  all 
important  factors  of  general  hygiene,  diet,  and  fresh  air  are  neglected 
because  of  their  use. 

Organotherapy  has  not  proved  of  sufficient  value  to  necessitate  dis- 
cussion at  present. 

The  recent  work  on  the  accessory  food  substances,  the  vitamins,  shows 
that  cod-liver  oil  contains  a  large  amount  of  the  anti-rickitic  element,  bear- 
ing out  the  previously  empirical  use  of  this  treatment.  Numerous  authors 
now  recommend  the  use  of  the  oil  without  the  phosphorus. 

The  use  of  emulsions,  while  it  greatly  facilitates  the  administration,  is 
to  be  avoided  because  of  the  small  percentage  of  cod-liver  oil  contained. 
Very  few  contain  over  fifty  per  cent,  and  most  commercial  preparations 
are  even  lower. 

Early  orthopedic  interference,  to  prevent  deformity,  is  inadvisable 
because  of  the  necessary  immobilization  which  could  only  result  in  further 
demineralization  and  softening.  In  severe  angular  deformities,  however, 
interference  may  be  imperative  even  in  infants  but  usually  braces,  etc., 
should  not  be  applied  until  school  age  is  reached.  In  some  cases,  the  further 


208  TEXT-BOOK  OF  PEDIATRICS 

demineralization  and  softening  produced  by  plaster  dressings  may  be  taken 
advantage  of  to  soften  the  bone.  Usually  about  six  weeks  will  soften  the 
bone  sufficiently  to  permit  molding  by  extension  and  massage. 

DIABETES  MELLITUS7 

The  disease  which  is  termed  true  diabetes  mellitus  occurs  much  more 
rarely  in  children  than  in  adults.  It  is  extremely  rare  in  the  first  years  of 
life,  but  is  somewhat  more  frequent  in  the  second  decade.  True  infantile 
diabetes  is  commonly  supposed  to  be  of  pancreatic  origin  and  closely  re- 
lated in  its  nature  to  that  which  develops  in  the  adult.  The  observations 
of  podiatrists  largely  sustain  the  view  that  the  condition  may  be  considered 
an  hereditary  endogenous  degeneration.  Degenerative  factors,  such  as  pa- 
rental lues  and  various  injuries  due  to  intermarriage  and  to  the  presence 
of  certain  homogeneous  stigmata,  frequently  appear.  Few  of  these  cases 
come  from  parents  of  the  middle  class. 

It  is  commonly  said  that  the  course  of  diabetes  in  childhood  is  uncom- 
plicated, but  rapidly  fatal.  That  it  is  ordinarily  under  observation  for  a 
short  period  is  probably  due  in  part  to  the  fact  that  the  condition,  because 
of  its  rarity  in  children,  is  not  suspected  and  for  this  reason,  is  diagnosed 
relatively  late  in  its  course.  Its  severe  stages  may  have  been  preceded  by 
disturbances  of  metabolism  extending  over  a  long  period,  without  exhibit- 
ing smy  marked  subjective  or  objective  signs.  The  transition  to  more  rapid 
progress  may  be  determined  by  some  infectious  disease  -or  other  injury. 
Only  when  the  tolerance  for  carbohydrates  quickly  decreases  or  has  already 
been  greatly  reduced,  so  as  to  cause  glycosuria  with  a  minimal  absorption 
of  sugar,  does  the  disease  become  noticeable.  Loss  of  weight,  weakness, 
lassitude,  occasional  pains  in  the  limbs,  marked  polydipsia  and  diuresis, 
often  leading  to  enuresis  and  irritation  of  the  external  genitals,  are  its  indi- 
cators. The  skin  is  dry  and  irritable.  Skin  affections,  as  urticaria  and  pyo- 
dermia,  occur  less  frequently  than  in  the  adult.  Very  often,  the  absence  of 
any  definite  sign  in  a  more  or  less  pronounced  illness  calls  attention  to 
the  possibility  of  diabetes  and  suggests  an  examination  of  the  urine  by  means 
of  which  the  diagnosis  is  established.  The  acetone  odor  may  also  serve  as 
a  guide. 

In  the  daily  quantity  of  urine,  which  may  amount  to  from  3  to  6  litres, 
we  may  find  several  grams  of  acetone  and  ammonia  (ammonia  coefficient, 
30-40  per  cent.),  large  quantities  of  acetoacetic  acid  and  oxybutyric  acid 
and,  at  times,  from  100  to  300  grams  (2-8  per  cent.),  of  glucose.  In  advance 
cases,  protein  and  casts  are  usually  found. 

Actual  or  pseudo-meliturias  of  a  non-diabetic  character  occur  much 
more  frequently  in  children,  and  especially  in  very  young  children,  than  in 
adults.  In  the  majority  of  these  cases  it  is  not  a  matter  of  glycosuria,  but 
of  the  output,  rather,  of  other  kinds  of  sugar  or  of  other  reducing  substances, 
the  nature  of  which  is  not  yet  fully  understood.  The  most  common  melituria 
in  the  infant  appears  to  be  a  lactosuria ;  that  is,  the  excretion  of  uncoverted 
sugar  of  milk.  Occasionally  a  galactosuria  occurs.  The  common  occasion 

7  For  the  pathogenesis  of  this  disease,  see  the  literature  of  internal  medicine.  Certain 
peculiarities  of  the  symptomatology  of  infantile  diabetes  are  briefly  considered  in  this  work. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  209 

of  these  disorders  is  some  disturbance  of  nutrition.  Many  children,  how- 
ever, of  the  lymphatic  type,  in  the  course  of  constitutional  diseases,  but 
without  manifest  disturbance  of  nutrition,  excrete  substances  which  give 
reactions  for  the  sugar  group.8  Furthermore,  the  acute  infections  predis- 
pose children  to  melituria,  usually  of  an  alimentary  type.  We  are  apt  to 
refer  the  fact  to  a  lowered  limit  of  assimilation  of  sugar,  failing  to  take  into 
account  the  truth  that  in  the  present  state  of  our  knowledge  of  the  renal  ex- 
cretion of  the  various  forms  of  sugar,  whether  monosaccharides  or  disac- 
charides,  we  must  recognize  more  than  one  fundamental  form  of  disturbance 
of  carbohydrate-metabolism.  Neither  a  continuance  of  glycosuria  for 
several  days  or  weeks,  nor  reliable  evidences  of  acidosis,  of  which  the  mere 
increase  of  the  ammonia  coefficient  is  not  adequate,  justify  a  diagnosis  of 
diabetes  in  these  cases.  Only  an  habitual  and  progressive  glycosuria,  a 
true  excretion  of  dextrose  with  a  decreasing  carbohydrate  tolerance,  asso- 
ciated with  general  symptoms,  are  conclusive. 

The  termination  of  diabetes  in  children,  practically  always  fatal,  is 
preceded  by  very  definite  signs  of  true  acidosis,  such  as  vomiting,  acetone 
breath,  jactitation,  and  coma  lasting  for  two  or  three  days.  The  average 
duration  of  the  disease  is  given  as  three  to  six  years,  while  its  more  severe 
period  laets  from  one  and  a  half  to  three  years  (v.  Noorden). 

The  treatment  of  diabetes  in  childhood  cannot  cure  the  disease,  but  may 
prolong  life.  It  is  essentially  dietetic.  Watching  with  the  greatest  care  the 
most  important  indications,  we  are  able  to  recede  from  that  absolutely 
rigid  withdrawal  of  carbohydrates  which  is  instituted  to  prevent  glycemia, 
and  thus  to  avoid  the  changes  of  autophagic  or  excessive  combustion  of  the 
body  fat  (acid  poisoning) .  In  the  treatment  of  acidosis,  it  is  customary  to 
attempt  neutralization  by  the  use  of  such  alkalies  as  sodium  bicarbonate  or 
citrate  in  teaspoonful  doses,  in  lemon  juice.  This  treatment  is  not  always 
successful  and  is  purely  symptomatic.  In  employing  it,  the  danger  of  the 
occurrence  of  edema  must  be  kept  in  mind.  The  dislike  of  the  patient  for  an 
exclusively  meat  and  fat  diet  sometimes  becomes  urgent. 

Oatmeal  is  not  only  better  borne  by  diabetics  than  are  other  starches  or 
sugars,  but  is  occasionally  found  to  increase  the  carbohydrate  tolerance. 
Van  Noorden 's  dietary  of  oat-products  is  based  upon  this  supposition.  It 
consists  of  a  diet  of  100  to  200  grams  of  oatmeal  gruel,  200  to  300  grams  of 
butter,  and  several  eggs  daily  for  a  period  of  one  or  two  weeks.  I  have  seen 
surprising  results  even  in  severe  cases,  but  the  gains  are  not  permanent. 
The  same  benefit  is  often  achieved  with  mashed  potatoes.  Inulin  and 
hediosit  are  harmless  but  expensive  carbohydrates.  Edibles  free  from  or 
poor  in  carbohydrates  are  meat  and  meat  broths,  ham  and  bacon,  aspic, 
green  vegetables  of  all  sorts,  cauliflower,  cheese,  cream,  sour  milk,  and  the 
various  factorial  food  preparations  for  diabetics.  The  statement  of  the 
manufacturers  concerning  the  carbohydrate  content  of  these  prepared  foods, 
is,  however,  frequently  open  to  doubt.  Recently,  protein  milk  has  received 
some  consideration.  Relatively  large  doses  of  alcohol  have  been  recom- 
mended (100  grams  per  day). 

8  Aschenheim  and  others. 
14 


210  TEXT-BOOK  OF  PEDIATRICS 

OBESITY 

Obesity  is  a  symptom  which,  in  extreme  form,  is  quite  rare;  but  in 
milder  degree  is  very  often  met  with  among  children,  especially  in  later 
childhood.  It  may  be  produced  by  various  causes.  The  most  frequent 
type  is  the  purely  ectogenous  or  alimentary  obesity  caused  by  the  use  of 
excessively  rich  food,  especially  in  the  form  of  carbohydrates  and  fats. 
Inquiry  into  the  child's  history  in  this  regard,  shows  that  its  food  require- 
ment has  been  over-estimated  by  the  parents.  The  child  is  often  actually 
overfed  even  though  the  fact  be  strenuously  denied.  Special  attention 
should  be  paid  to  the  habit  of  eating  between  meals,  to  the  use  of  milk  as  a 
beverage,  to  a  dietary  of  sweets,  artificial  foods,  etc.  Alcoholism,  to  the 
frequency  of  which  in  childhood  Hecker  and  others  have  testified,  must  also 
be  considered.  Both  the  laity  and  physicians,  learning  of  the  low  nutritive 
value  of  alcohol,  fail  to  include  it  as  a  heat-producing  material  in  their 
caloric  estimates;  although  beer,  for  instance,  represents  a  caloric  value 
two-thirds  that  of  milk. 

In  another  class  of  cases,  the  quantity  of  food  is  only  relatively  in 
excess;  that  is,  in  proportion  to  the  abnormally  small  amount  of  muscular 
work  and  bodily  exercise  undertaken  by  the  child.  This. may  be  due  to 
laziness  caused  by  heredity,  training  or  example,  etc.,  and  is  comparable  to 
the  fattening  of  the  animals  for  market ;  or  it  may  be  caused  by  disease 
which  in  its  course  develops  myopathic  or  skeletal  disorders,  pain  upon  mus- 
cular contraction,  etc.  (rickets,  paralyses).  In  this  group  the  signs  of 
basic  disease  are  often  hidden  beneath  the  obesity.  It  may  occur,  for  in- 
stance, in  certain  endogenous  forms  of  nerve  disease,  as  in  the  hereditary 
ataxia  of  Werdnig-Hoffmann.  Such  cases  represent  a  transition  to  true 
endogenous  obesity,  which  alone  may  be  termed  a  true  adiposis. 

These  adiposes  are  etiologically  divisible  into  two  types;  those,  on  the 
one  hand,  which  constitute  a  phenomenon  of  hypo-  or  athyroidea;  and, 
those,  on  the  other  hand,  which  are  sequela  to  hypoplasias  and  to  func- 
tional errors  in  the  germinal  organs  (castration,  genital  infantilism,  etc). 
The  absence  or  functional  incapacity  of  these  glands  of  internal  secretion 
leads  to  a  retardation  of  the  metabolism,  a  result  experimentally  proven. 
Of  similar  origin  are  those  forms  of  endogenous  obesity  which,  developing 
wholly  without  symptoms,  offer  no  definite  points  of  departure  for  etiologic 
study.  With  respect  to  the  pathogenesis  of  these  conditions  clinical  opinion 
has  for  centuries  favored  the  idea  of  an  hereditary  constitutional  anomaly,  of 
a  reversion  of  cell  function  due  to  a  reduction  of  the  total  metabolic  values 
of  the  germinal  cell.  For  a  long  time,  this  view  could  not  be  sustained  by 
experimental  observation.  Evidently  suitable  cases  had  failed  of  analysis 
— those  exceptional  cases  which  maintain  their  excessive  weight  upon  an 
extraordinarily  small  amount  of  food;  in  which,  for  instance,  an  energy 
quotient  of  seventeen  under  bodily  exercise  and  of  twelve  under  rest,  being 
about  one-third  of  the  normal  standard,  persists  for  weeks  and  months. 
Very  recently,  however,  it  has  been  actually  determined  that  among  these 
adiposes  are  individuals,  some  of  them  young  and  without  myxedema  or 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS 


211 


genital  infantilism,  who  have  an  habitually  reduced  metabolism,  who 
actually  "use  less  fuel"  than  others  (v.  Bergmann). 

Finally,  we  must  consider  as  a  pathogenic  possibility  a  special  disturb- 
ance of  fat  metabolism.  If  it  be  true  that  certain  lipolytic  ferments  of 
the  lymphocytes  are  concerned  in  the  catabolism  of  the  body  fat,  the  rela- 
tion of  obesity  to  certain  systemic  diseases  of  the  lymphatic  organs,  such  as 
hypoplasia  and  hyperplasia  would  be  explained  in  accord  with  clini- 
cal observations. 

The  treatment  of  obesity  in  children  must  take  this  factor  into  account. 
Therapeutic  measures  addressed  to  cause  are  effective  in  many  cases  in 
which  the  condition  is  brought  on  by  overfeeding,  alcoholism,  irregular 
living,  or  hypothyreosis.  In  the  matter  of 
diet,  caution  must  be  exercised  to  avoid  the 
loss  of  nitrogen.  For  this  reason,  the  use  of 
preparations  of  the  thyroid  gland,  when  the 
gland  is  functionating  normally,  is  generally 
contraindicated.  According  to  Hellesen  it  is 
more  difficult  to  prevent  loss  of  nitrogen  in 
the  dietetic  treatment  of  obesity  in  children 
than  it  is  in  adults.  The  total  food  supply 
estimated  by  its  energy  value,  should  never 
be  reduced  below  fifty  calories  per  kilogram 
of  net  body-weight  when  at  rest.  The  body- 
weight  to  be  reckoned  in  such  estimates 
should  be  the  mean  of  the  individual 's  pres- 
ent weight  and  his  normal  weight  for  his 
given  height.  A  bulky  diet  generous  enough 
to  satisfy  the  appetite  and  containing  ample 
nitrogen,  water  and  cellulose,  but  poor  in 
fats  and  carbohydrates,  should  be  selected. 
It  is  not  necessary  to  curtail  the  quantity  of 
water,  as  the  obese  person  loses  more  water 
during  exercise  than  the  normal  individual. 

.,  ,  .,        .   ,,         .  .  boy.   (University  Children  s  Hospital, 

For  older  children  the  following  regimen      Bfesiau,  Prof.  Tobier.) 
may  be  suggested.    At  noon,  an  abundant 

allowance  of  broth;  later  a  meal  consisting  of  meat  and  vegetables  (cabbage, 
spinach,  turnips,  etc.)  and  for  the  rest  of  the  meals  skimmed  or  preferably 
separated  milk,  or  tea  sweetened  with  benzosulphinidum  (saccharin),  bread, 
a  little  honey  and  fruits.  Water  may  be  given  freely.  Active,  but  regulated 
physical  exercise  should  be  prescribed.  In  individual  cases  an  exact  esti- 
mate of  the  food  taken  should  give  its  caloric  value. 

UNDER-NOURISHED  OR  FRAIL  CHILDREN 

The  question  of  persisting  leanness  or  even  emaciation  in  children  is 
frequently  met  with  in  practice.  A  discussion  of  the  causation  of  this  con- 
dition must,  however,  take  innumerable  factors  into  consideration.  In  the 
first  place,  the  persisting  leanness  may  be  the  result  of  a  long  wasting  disease 


Fio.   53. — Obesity,   twelve-year-old 
y.   (University  Child 
Breslau,  Prof.  Tobler.) 


212  TEXT-BOOK  OF  PEDIATRICS 

from  which  the  patient  has  recovered  but  never  got  back  to  his  full  robust 
energy.  Chief  among  such  conditions  is  tuberculosis  with  its  variable  mani- 
festations and  its  slow  recovery.  Then  chronic  toxic  infectious  injuries  to 
the  nutritive  apparatus  may  be  rated.  In  the  second  place,  the  cause  of 
emaciation  may  be  due  to  the  food  itself.  The  starved  looking  urchin  may 
never  have  had  enough  to  eat  or  the  food  may  have  been  poor  in  quality  and 
wretchedly  prepared.  Then  again,  there  may  be  certain  mechanical  inter- 
ferences with  the  assimilation  of  the  food.  Among  these  we  may  have 
pyloric  stenosis,  cardiospasm,  and  esophageal  obstruction,  with  persistent 
vomiting  and  wreching. 

Inanition  occurs  frequently  in  infants,  not  by  any  fault  of  the  mother, 
but  as  a  result  of  poorly  functioning  breasts,  or  of  insufficient  artificial  food 
at  times  on  the  advice  of  the  physician  or  commonly  upon  following  the 
directions  on  the  box  of  some  patent  infant-food. 

However,  all  of  the  above  factors,  which  really  require  no  further  discus- 
sion, cover  only  a  small  percentage  of  the  large  number  of  children  that  can 
be  classed  as  "under-nourished."  Indeed  it  can  easily  be  shown  that  these 
children  do  not  react  to  food  as  one  would  expect  of  a  hungry  child.  Addi- 
tions to  the  diet  do  not  result  in  any  marked  increase  in  weight.  Nor  do 
they  present  the  characteristic  objective  signs  of  inanition. 

Even  this  class  of  lean  or  frail  children  is  not  an  entity.  After  eliminat- 
ing those  cases  in  which  the  leanness  exists  only  in  the  imagination  of  the 
mother  whose  ideal  of  childhood  is  the  fat  pasty  infant,  or  who  interprets 
the  period  of  growth  in  height  as  an  abnormal  phenomenon,  we  still  have 
those  children  in  whom  there  is  a  true  lack  of  fat  (lean  in  the  narrowest 
sense),  those  who  are  poorly  muscled,  and  those  that  are  especially  small 
boned  (asthenic). 

In  our  present  system  of  education  and  training,  the  development  of  the 
musculature  by  proper  exercise  is  often  sadly  neglected,  especially  in  chil- 
dren from  six  to  twelve  years  of  age.  This,  naturally,  results  in  boys  and  girls 
with  small  legs  and  arms  even  though  the  panniculus  is  fairly  abundant. 
This  child,  because  of  insufficient  exercise,  requires  little  food  and  is  sup- 
posed to  be  sick.  Others  are  lean  because  of  actual  anorexia.  In  such,  the 
anorexia  may  be  due  to  a  vitiated  taste,  spoiled  by  highly  flavored  candies 
and  desserts,  spiced  foods  and  carbonated  drinks.  Protracted  anorexia 
brings  with  it  other  unpleasant  symptoms  such  as  dulness,  restlessness, 
disobedience  and  lack  of  concentration  at  lessons.  Grouped  together  these 
manifestations  are  often  called  "school  sickness." 

Still  another  group  of  the  so-called  "frail"  children  is  found  in  the  high- 
strung,  fretful,  restless,  neuropath.  They  may  be  individuals  of  distinctly 
abnormal  bodily  and  mental  excitability,  born  as  such  or  brought  up  in  this 
way  by  the  constant  association  with  members  of  the  family  similarly 
afflicted.  Of  weak  will-power,  they  are  urged  on  physically  and  subjected  to 
outbursts  of  temper,  etc.,  until  they  'themselves  become  neuropathic. 
These  stimuli  can  often  be  traced  into  early  influences. 

A  certain  stress  must  also  be  laid  upon  heredity.  It  is  not  at  all  uncom- 
mon to  find  that  the  father  or  mother  presents  the  same  characteristics  of 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  213 

growth  as  does  the  child.  Or  one  of  the  parents  may  have  been  of  a  similar 
build  at  the  same  age.  There  is  no  doubt  that  the  failure  of  panniculus, 
etc.,  is  as  transmissible  as  obesity.  In  connection  with  this,  attention  must 
be  drawn  to  the  fact  that  the  association  of  hereditary  leanness,  with  vary- 
ing degrees  of  stigmata  of  degeneration,  is  not  at  all  uncommon.  We  may 
indeed  speak  of  a  "degeneration  form  of  frailness. " 

Remembering  the  discussion  under  obesity  concerning  children  who  are 
fat  because  of  a  lower  metabolism  (slow  oxidation)  it  may  be  assumed  that 
there  are  individuals  who  have  a  habitually  more  active  metabolism  and  a 
resulting  leanness.  This,  of  course,  has  not  been  shown  by  metabolism  test. 

Finally,  it  is  definitely  known  that  there  are  children  that  do  not  thrive 
upon  a  diet  upon  which  others  of  the  same  age  and  in  the  same  surroundings 
grow  at  the  accepted  normal  rate. 

TREATMENT 

The  frail  children  of  the  well-to-do  regularly  become  the  sacrifices  of  the 
rather  "  hypertrophic  "  industry  of  advertised  foods.  The  discussion  of  the 
causation  of  the  condition  is  really  quite  enough  to  lead  the  physician  into 
proper  therapeutic  paths.  Careful  scrutiny  of  the  dietary  with  corrections, 
giving  simple  but  sufficient  nourishment,  should  not  be  neglected. 

PECULIAR  PREDISPOSITIONS  TO  DISEASE  (DIATHESES); 
AND  CONSTITUTIONAL  ANOMALIES 

In  certain  children  a  remarkably  frequent  appearance  of  peculiar  dis- 
turbances of  health  is  observed  and  this  in  the  face  of  the  exercise  of  the 
greatest  care  in  the  avoidance  of  injuries  which  are  recognized  as  standing 
in  causative  relation  to  such  disorders.  In  view  of  this  evident  fact,  we  are 
forced  to  conclude  that  in  such  children  some  organic  peculiarity  exists, 
a  special  disposition  or  a  favorable  soil,  as  it  were,  for  the  agents  of  disturb- 
ance. Instead  of  the  phrase  " predisposition  to  disease,"  the  Greek  term 
diathesis  has  come  into  common  use.  The  abnormalities  to  which  the 
organism  may  show  such  predisposition  are  of  varying  character.  They 
may  belong,  for  instance,  to  the  group  of  catarrhal  affections  of  the  mucous 
membranes  and  the  skin,  or  to  forms  characterized  by  swelling  of  the  lymph 
nodes ;  or  to  the  type  of  neuropathic  disorders.  We  may  speak,  therefore,  of 
a  catarrhal  diathesis,  of  a  lymphatic  diathesis  or  of  a  neuropathic  diathesis 
without  standing  committed  to  any  hypothesis,  but  expressing  simply  fact* 
supported  by  numerous  observations.  Such  a  diathesis  is  not  a  disease,  but 
merely  a  state  of  predisposition  to  certain  forms  of  disease.  The  principle 
of  this  conception  has  been  often  disputed,  but  never  logically  disproved. 
The  elements  which  determine  the  diathesis  induce  manifestations  which 
often  differ  but  slightly  from,  or  are  closely  identical  with,  those  which 
figure  in  the  diseases  of  individuals  not  so  predisposed.  In  other  cases, 
again,  these  manifestations  represent  not  only  quantitative,  but  qualita- 
tive reactions  of  the  organism  to  pathologic  irritation  which  are  essentially 
abnormal  or  illegimate.  They  exhibit,  indeed,  certain  stigmata,  which  call 


214  TEXT-BOOK  OF  PEDIATRICS 

the  attention  of  the  experienced  observer  to  constitutional  peculiarities 
which  may  underlie  the  condition. 

All  diatheses,  however,  are  not  definitely  latent.  There  are  predis- 
positions to  disease  which  are  continually  manifest,  whether  as  persistent 
sequelae  to  distinct  attacks  of  disease,  or  as  externally  recognized  deviations 
of  structure  or  quality  from  the  normal  habitus.  The  term  constitutional 
anomaly  is  often  applied  to  this  type  of  cases. 

A  further  diathetic  fact  is  that  different  predispositions  to  disease  may 
be  combined  in  one  individual.  Thus  we  frequently  find  the  predisposition 
to  catarrhal  disease  associated  with  the  tendency  to  involvement  of  the 
lymphatic  tissues.  In  these  cases,  moreover,  the  swelling  of  the  lymph  nodes 
cannot  be  regarded  as  a  consequence  of  the  catarrhal  condition  of  the  skin 
and  mucous  membranes.  The  two  states  are  rather  in  large  measure  co- 
ordinate to  each  other;  and  the  fact  justifies  us  in  recognizing  a  combined 
catarrhal  and  lymphatic  diathesis.  Frequently  another  member  of  the 
diathetic  group  may  be  associated,  viz.,  the  predisposition  to  nervous 
disease  giving  a  combined  neurolymphatic  diathesis.  Desirable  as  it  may 
be  to  make  advances  in  this  difficult  field  by  distinct  classifications  and 
divisions,  it  must  not  be  forgotten  in  the  desire  for  a  schematic  presentation 
of  the  subject,  that  as  every  observer  knows  from  his  own  experience,  that 
combined  diatheses  are  frequently  met  with  in  practice. 

THE  INFLAMMATORY  OR  EXUDATIVE  DIATHESIS 

For  the  podiatrist  this  is  the  most  important  of  all  the  abnormalities 
belonging  in  this  group.  The  condition  was  described  by  Theo.  White, 
among  others,  in  1782  ar  d  has  recently  been  reviewed  by  Czerny. 

Occurrence. — The  exudative  diathesis  is  a  widely  distributed  condition 
and  in  frequency  can  be  compared  with  rickets.  It  is  recognized  more  of- 
ten than  rickets  by  the  physician  because  its  manifestations  continue  for 
a  longer  period.  The  tendency  is  familiar.  Heredity,  especially  through  the 
mother,  plays  an  important  part;  exhibiting  itself  chiefly  in  homologous, 
but,  also,  in  heterologous  types. 

Initial  Appearances. — The  condition  is  not  discoverable  usually  in  the 
new-born.  Apparently  the  maternal  organism  exerts  a  sort  of  protective 
influence,  as  it  does  in  certain  disturbances  of  the  organs  of  internal  secre- 
tion, for  example,  in  aplasia  of  the  thyroid.  The  smallness  and  delicacy  of 
the  child  are  no  more  indications  of  the  diathesis  than  is  a  long  lock  of  hair 
standing  on  end  over  the  coronal  suture.  Suspicion  may,  however;  be 
aroused  by  delayed  reaction  from  the  initial  weight-loss  following  birth, 
or  by  an  early  flattening  of  the  weight-curve  in  spite  of  an  adequate  sup- 
ply of  natural  food.  This  may  suggest  a  combination  of  the  diathesis  with 
disturbances  of  growth  and  development.  Such  a  diagnosis  must  be  made, 
however,  with  exceeding  care. 

Characteristic  evidences  of  this  predisposition  to  inflammatory  disease 
and  to  changes  in  the  composition  of  the  body  as  a  whole  usually  appear 
only  after  the  first  few  weeks. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS 


215 


1.  The  habitus  of  the  diathesis  is  variable.    Two  types  are  recognized; 
that  of  the  delicate,  weak,  exudative  patient  and  that  of  the  large,  appar- 
ently strong  and  fat,  but  muscularly  weak  child.    The  latter  type  is  fre- 
quently met  with  in  a  singular  variety,  to  which  A.  Paltauf  has  applied  the 
term:  status  thymico-lymphaticus.     This  type    tends   to    become    patho- 
logically fat  and  shows  a  pallor  due  rather  to  ischemia  than  to  true  anemia, 
and  in  part  due  to  the  increased  water  content  and  the  reduced  turgor  of 
the  subcutaneous  tissues.    This  form  is  also  called  the  "pasty"  habitus. 

2.  A  more  or  less  constant  hyperplasia  of  the  thymus  and  of  the  lymph 
nodes  is  usually  associated  with  the  latter  habitus.    Its  clinical  signs  are  as 
follows:  moderately  hard,  palpable  tumors  of  the  lymph  nodes  in  the  neck, 
over  the  inner  aspect  of  the  joints  and  perhaps,  in  the  abdomen;  an  enlarge- 
ment of  the  spleen,  a  visible  hyperplasia  of  the  faucial  and  pharyngeal 
tonsils,  with  a  redundancy  of  the  circumvallate  papillae. 

Infantilism  is  of  less  frequent  appearance  and  is  usually  first  noticed  in 
older  children.  It  consists  in  delay  of  the  development  of  the  body  in  point 
of  size  and  in  the  secondary  sexual  characteristics. 

3.  Certain  manifestations  of  the  diathesis  appear  upon  the  surfaces  of 
the  body  and  are  apt  to  have  certain  sequelae  and  complications.  The  follow- 
ing table  gives  an  outline  of  these  tendencies. 

MANIFESTATIONS  OF  THE  EXUDATIVE  DIATHESIS 


Seat 

Primary  forms 

Secondary  forms 

Sequelae  and  complications  usually 
of  "nervous"  quality 

The  skin. 

Seborrhoea  cap- 
itis,  crusta  lac- 
tea,  intertrigo, 
prurigo. 

Eczema,   impe- 
tigo, abscesses. 

Severe    itching,-   great    restlessness, 
distybed    sleep,   readily  induced 
frigh  . 

The   mucous 
membranes. 

Transient    des- 
quamation  and 
turgescence   in 
various  regions 

Exudative  proc- 
esses. Palatal 
angina,  phar- 
yngitis. 

Hyperpyrexia,  cough,  vomiting, 
anorexia. 

Gastro  enteri- 
tis. 

Vomiting,  pylorospasm,   colic, 
obstipation,  mucomembranous 
diarrhoea. 

Coryza,  laryn- 
gitis, bron- 
chitis, bron- 
chiolitis. 

Hay  fever, 
pseudo  cough, 
convulsive  cough, 
bronchial  asthma. 

Conjunctivitis, 
phlyctenuUe, 
blepharitis. 

blepharospasm. 

Balanitis,    vul- 
vovaginitis, 
cystitis. 

dysuria,  ischuna. 

The  lymphatic 
organs. 

Hyperplasia  of  the  faucial  and  pharyngeal  tonsils. 
Hyperplasia  of    the    palpable   lymph  nodes  in  the   neck  and 
the  joints. 

at 

216 


TEXT-BOOK  OF  PEDIATRICS 


The  appearance  of  milk-crusts,  seborrhoeic  deposits,  and  intertrigo  is 
usual  in  the  first  year.  Prurigo 9  may  occur  later.  Anemic  catarrhal  affec- 
tions and  the  hyperplasia  of  the  lymph  nodes  which  occur  throughout  in- 
fancy and  childhood  may  also  be  present,  to  a  degree,  in  the  nursing  infant. 

The  milk-crust  or  vesicular  eczema  of  the  scalp  appears  as  an  exudate  in 
the  form  of  dark  gray  or  brown  scales  which  become  firmly  attached  to  the 
epidermis.  The  skin  beneath  them  is  of  bright  red  color  and  moist.  EC- 


FIG.  54. — Pasty  habitus,  especially  in  the  face.    Beginning  eczematous  eruption. 

zema  rubrum  with  a  white  bran-like  desquamation  occurs  in  sharply  cir- 
cumscribed triangular  areas  of  reddened  and  thickened  epithelium  upon 
the  cheeks. 

Intertrigo  or  chafing,  which  in  healthy  but  neglected  children  occurs 
around  the  anus  and  the  genitalia,  develops  in  others  also  behind  the 

9  Prurigo  occurring  in  lean  children,  forms  diffuse,  hard  yellow  itching  nodules 
(lichen');  which,  in  fat  children,  are  preceded  by  red  papules  (urticaria  rubra).  These 
lesions  develop  chiefly  on  the  nates,  the  body,  the  legs  and  arms,  but  hardly  ever  on  the 
face.  The  term  lichen  urticatus  or  strophulus  is  often  confused  with  the  quite  different 
prurigo  of  Hebra. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  217 

ears,  in  the  wrinkles  of  the  neck  and  in  the  folds  of  the  joints.  In  any  of 
these  skin  conditions,  scratching  and  uncleanliness  may  cause  infection, 
and  the  appearance,  in  consequence,  of  a  severe,  obstinate,  wet,  impetig- 
inous  eczema 

Geographical  tongue  is  caused  by  exudations  occurring  in  striae,  over 
the  upper  surface  of  the  tongue.  Prominence  of  the  papillae  and  desquama- 
tion  of  the  epithelium  give  the  characteristic  white  color  to  these  lines. 

Primary  disorders  of  the  skin  and  mucous  membranes  are  probably  of 
identical  nature.  The  process  consists  essentially  of  a  superficial  desquama- 
tion  and  an  accompanying  exudation.  The  definite  localization  of  these 
lesions,  suggestive  of  local  injury  or  dystrophy,  and  their  appearance  as 
distinct  attacks  without  any  apparent  external  cause  are  especially  char- 
acteristic. The  lesions  appear  singly  or  in  the  most  variable  relation. 
Eczema  rubrum,  prurigo  and  especially  the  geographical  tongue  are  trans- 
itory and  change  their  appearance  daily. 

Czerny  claims  that  the  catarrhal  manifestation  of  the  diathesis  are 
analogous  to  the  eczemata  and  may  also  be  laid  to  infections  for  which 
the  soil  has  been  prepared  by  the  irritable  condition  of  the  mucous  mem- 
branes. Numerous  observers  note  catarrhal  affections  of  the  mucosa  of  the 
digestive  tract  which  are  quite  different  and  of  early  occurrence.  They  are 
indicated  by  diarrhoea,  muco-  and  sanguine-purulent  stools  with  eosino- 
philic  cells.  They  are  not  attended  by  severe  general  symptoms.  Obsti- 
pation and  a  fetid  breath  usually  accompany  the  throat  conditions.  In  half 
of  the  "exudative  infants"  Lust  finds  an  organized  urinary  sediment,  con- 
sisting of  epithelial  cells  and  leucocytes,  arising  from  a  desquamative  proc- 
ess which  runs  a  definite  course  and  increases  the  disposition  to  infectious 
catarrhs.  (Colon  pyelocystitis.) 

These  infectious  processes  in  the  skin  and  mucous  membra.nes  increase 
in  a  degree  the  hyperplasia  of  neighboring  lymph  nodes  and  of  the  tonsils ;  a 
hyperplasia  which  in  these  diatheses  may  be  produced,  also,  by  alimentary 
injuries,  etc.  The  marked  and  permanent  hyperplasiae  of  the  faucial  and 
pharyngeal  tonsils  and  their  sequelae,  discussed  in  detail  in  other  parts  of 
this  work,  arise  in  this  manner. 

4.  An  increased  liability  to  disease  and  a  heightened  reaction  to  causes 
of  irritation,  which  the  exudative  diathesis  carries  with  it,  may  be  mani- 
fested also  in  other  functional  systems.  Children  so  affected  are  commonly 
prone  to  disorders  of  metabolism;  they  are  disposed  to  disturbances  of 
nutrition  of  varying  degree,  to  spasmophilic  phenomena  and  to  functional 
and  structural  changes  in  the  vascular  mechanism,  in  the  way  of  palpitation, 
cardiac  dyspnoea,  and  dilatation  and  hypertrophy  of  the  heart. 

In  the  status  thymico-lymphaticus  sudden  death,  primarily  due  to  heart 
failure,  often  occurs.  It  may  follow  immediately  after  birth  or  happen  at  a 
later  period  without  any  evident  cause  or  upon  such  slight  provocation  as 
overfeeding,  anesthesia  or  the  excitement  attendant  upon  a  slight  operation, 
especially  when  this  involves  the  throat,  or  upon  the  application  of  band- 
ages, the  use  of  baths  or  other  hydrotherapeutic  procedures. 

In  all  cases  in  which  death  occurs  without  preceding  illness,  the  thymus 


218  TEXT-BOOK  OF  PEDIATRICS 

is  found  to  be  relatively  large.  It  is  an  organ  especially  affected  in  all  the 
retrogressive  changes  of  infancy.  It  has  been  suggested  that  the  measure- 
ments of  the  thymus  taken  in  event  of  thymic  death  were  normal  and  that 
they  were  counted  abnormal  only  because  they  were  compared  with  the 
measurement  of  the  organ  taken  from  cachectic  bodies.  This  error  may 
have  entered  into  the  estimate  occasionally,  but,  nevertheless,  in  the  con- 
dition under  discussion  of  enlargement  of  the  thymus  is  definitely  estab- 
lished by  accurate  observations.  The  organ  may  be  said  to  be  enlarged 
when  it  weighs  more  than  twenty  grams  in  infancy  and  more  than  thirty 
grams  in  early  childhood. 

Where  very  young  children  have  suffered  from  tetany  and  laryngo- 
spasm  for  a  time,  or  when  they  have  gradually  developed  symptoms  resem- 
bling intoxication,  death  comes  less  unexpectedly. 

The  ultimate  cause  of  death  in  cases  of  status  thymico-lymphaticus  has 
not  been  determined.  The  presence  of  a  thymic  tumor  has  been  especially 
considered.  It  appears,  however,  that  the  mechanical  pressure  of  the 
enlarged  organ  involving  the  trachea,  bronchi,  nerves,  blood-vessels,  or 
esophagus,  does  not  often  play  an  important  part.  We  are  inclined  to  look 
upon  the  result,  as  one  arising  from  a  pathologic  secretion  from  the  thymus, 
a  hyper-  or  hypo-thymusation,  which  is  not  necessarily  associated  with 
enlargement  of  the  organ.  The  more  recent  view  is  that  enlargement  of  the 
lymphatic  glands  or  of  the  thymus  is  not  the  actual  cause  of  this  sudden 
death,  but  rather  that  it  is  a  coordinative  consequence  of  a  severe,  even 
though  latent  general  disturbance. 

All  of  the  manifestations  of  the  exudative  diathesis  continue,  usually, 
but  with  longer  or  shorter  interruptions,  up  to  the  tenth  to  the  fourteenth 
year.  Early  childhood  is  the  most  severely  affected  period.  Toward  puberty 
a  recession  of  symptoms  is  usually  noticeable.  Continuance  or  relapse  after 
puberty  is  rare. 

Diagnosis. — The  experienced  observer  is  often  able  to  make  the  diag- 
nosis of  an  exudative  diathesis  instantly  from  the  habitus  of  the  patient, 
or  from  the  characteristic  tendency  to  illness  arising  spontaneously  or  from 
a  very  slight  injury. 

Possible  findings  in  the  body  fluids  in  the  way  of  relative  lymphocytosis, 
eosinophilia,  dietetic  hyperglycemia,  and  melituria  are  of  very  limited 
value  from  a  diagnostic  standpoint.  This  is  also  true  of  the  test  devised  by 
Rachmilewitsch,  which  consists  in  the  formation  of  papules  when  a  skin 
lesion  is  irritated  by  the  application  of  mustard  paste. 

The  value  of  findings  by  percussion  or  by  the  Roentgen  ray,  in  demon- 
strating an  enlargement  of  the  thymus,  either  by  dulness  or  by  a  shadow 
deepening  to  the  left,  must  be  carefully  weighed.  A  valuable  diagnostic 
point  is  found  in  inspection  of  the  follicles  at  the  back  of  the  tongue. 

Ultimate  Nature. — The  various  hypotheses  as  to  the  nature  of  the  pre- 
disposition to  inflammatory  disease  are  more  or  less  vague.  The  theories 
of  a  primary  anomaly  of  metabolism,  of  chemical  malformation,  of  endo- 
genous food  injuries,  of  disturbances  in  the  regulation  of  the  water  content 
of  the  tissues  are  among  them,  and  these  have  been  recently  attacked. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  219 

Aschenheim  and  Tomono  could  not  support  the  theory  of  Eppinger 
and  Hess  that  the  exudative  diathesis  is  based  upon  a  vagus  hypertonia. 
The  careful  investigations  of  H.  and  L.  Hirschfeld  show,  moreover,  that 
the  serum  of  exudative  patients  has  a  marked  vasoconstrictive  action. 
Similarly,  according  to  Samelson,  the  therapeutic  results  obtained  by 
Krasnogorski  with  atropin,  which  apparently  gave  support  to  the  vagus 
hypertonia  theory,  are  problematic.  Nevertheless,  there  is  something 
tangible  in  the  proposed  relation  between  the  status  lymphaticus  and 
this  condition 

The  exudative  diathesis  has  a  demonstrable  structural  basis,  in  a  definite 
overgrowth  of  the  several  parts  of  the  lymphatic  system.  This  hyper- 
plasia  affects  the  lymph  nodes  of  the  neck,  the  axilla,  the  prevertebral 
chain,  the  intestinal  submucosa,  the  mesentery,  the  spleen,  the -follicles 
of  the  nasopharynx,  the  base  of  the  tongue  and  the  gums. 

Together  with  this  general  hyperplasia,  there  is  also  a  new  formation 
of  lymph  follicles  in  the  liver,  thyroid  and  bone-marrow,  and,  finally, 
an  enlargement  of  the  thymus.  This  enlargement,  according  to  Schridde, 
consists  of  a  hyperplasia  of  the  medulla  and  a  hypoplasia  of  the  cor- 
tex of  the  organ,  with  atypical  corpuscles  of  Hassal.  As  general  mani- 
festations we  note  a  characteristic  pallor  of  the  skin  and  an  increase  of 
the  panniculus  adiposus.  Other,  but  inconstant  findings,  are  a  hypoplasia 
of  the  vascular  system,  of  the  chromaffin  system  (the  suprarenal  me- 
dulla and  the  solar  plexus),  of  the  cerebrospinal  and  genital  systems  and, 
lastly,  various  malformations  which  result  from  a  general  developmen- 
tal failure. 

According  to  Bartel  and  Stein's  preliminary  reports,  the  cause  of  the 
changes  in  the  lymph  nodes  is  a  failure  in  the  development  of  the  lymph 
channels  and  of  the  medullary  stria3  of  the  lymph  nodes,  with  a  prolifer- 
ation of  the  zone  of  cortical  follicles  in  the  first  stage  of  growth  and  a 
secondary  atrophy  of  their  specific  parenchyma.  The  atrophy  of  the 
remaining  lymphoid  tissue  is  probably  compensatory.  The  process  may  be 
described  as  a  developmental  error,  the  first  results  of  which  appear  in  the 
connective  tissues  and  directly  involve  the  lymph  nodes.  These  results, 
accordingly  are  the  expression  of  a  general  hypoplastic  tendency  in  the 
genesis  of  which  the  fiypoplasia  of  the  vascular  system,  possibly,  plays  a 
primary  and  fundamental  role. 

This  conception  agrees  with  that  which  the  author  had  reached  from  a 
different  point  of  approach.  A  congenital,  or  a  true  hereditary  weakness  of 
various  organic  systems  reduces  their  capacity  and  their  resistance.  This, 
in  turn,  results  in  an  increased  and  qualitatively  different  reaction  to  natural 
stimuli  which,  under  ordinary  circumstances,  would  not  be  pathogenic,  but 
with  this  diathesis,  provoke  the  manifestations  of  disease.  According  to  its 
capacity  to  respond  to  demands  made  upon  it,  the  weakened  parenchyma 
may  be  strengthened  by  exercise  or  injured  by  excessive  use.  In  the  above 
case,  we  may  have  also  accompanying  the  general  connective  tissue,  diatheses, 
multiple  scleroses  in  the  various  endocrine  organs  causing  deficiency 
disturbances  (plui  iglandular  insufficiency  of  Wiesel). 


220  TEXT-BOOK  OF  PEDIATRICS 

Exudative  infants  constitute  a  pathologic  species  of  unnumbered 
variety.  The  combined  diatheses  break  up  into  component  predispositions, 
each  of  which  depends  upon  the  functional  weakness  of  a  particular  system 
and  results  in  the  tendency  to  a  definite  symptom-complex.  From  tests  of 
the  functional  capacity  of  affected  organs,  criteria  of  the  component  predis- 
positions may  be  obtained. 

The  injuries  which  produce  inflammatory  conditions  upon  the  basis  of 
this  existing  increased  predisposition  to  disease  are  very  many.  Irrational 
forms  of  dietary  and  particularly  those  which  are  popularly  termed 
"strengthening,"  but  are  merely  causative  of  the  excessive  formation  of 
fat,  are  among  the  most  active  of  these  injuries  and  that  irrespective  of  the 
preponderance  of  their  protein,  fat  or  carbohydrate  components.  Accord- 
ing to  Czerny,  the  most  injurious  consequence  of  such  a  fattening  process  is 
the  increased  disposition  it  affords  to  secondary  infections,  which  favor  the 
development  of  severe  and  often  dangerous  secondary  changes.  It  is  an 
accepted  fact  that  dietetic  injuries  produce  disease  symptoms  more  readily 
when  they  occur  in  patients  who  are  subject  to  this  complex  abnormality 
which  we  term  the  exudative  diathesis.  Too  great  stress,  however,  must 
not  be  put  upon  the  effects  of  overfeeding  in  the  pathogenesis  of  these 
disturbances.  The  writer  discerns  a  tendency  to  exaggerate  their  im- 
portance when  authorities  call  attention  to  the  striking  and  constant  influ- 
ence which  the  manner  of  feeding  has  upon  individual  symptoms  and 
regard  this  alleged  fact  as  a  criterion  in  the  recognition  of  the  picture  of 
a  diathesis. 

As  factors  which  may  convert  a  latent  diathesis  into  an  active  process 
with  characteristic  signs  of  its  presence,  we  must  reckon  with  certain  inter- 
current  infectious  diseases,  as  tuberculosis  and  measles.  Even  vaccination, 
the  application  of  the  tuberculin  test,  or  the  accident  of  an  insect  bite  may 
serve  as  the  spark  which  lights  up  the  potential  tendency.  With  the  pre- 
disposing hypersensitivity  of  the  body  surface,  mechanical,  thermic,  actinic 
and  sensory  irritants  may  act  as  the  agents  of  injury. 

Exudative  diathesis  and  the  status  lymphaticus  are  frequently  but  not 
inevitably  associated.  Their  relationship  is  shown  in  the  fact  of  their 
frequent  reaction  to  similar  influences,  as  seen  in  their  tendency  to  improve 
under  the  dietetic  measures  prescribed.  Czerny  and  others  consider  the 
status  lymphaticus  as  a  component  element  in  the  severer  forms  of  exuda- 
tive diathesis.  Unquestionably,  the  latter  stands  in  close  association  with 
certain  neuro — and  psychopathies.  The  irritability  and  instability  of  the 
nervous  system  of  children  of  exudative  diathesis,  exerting,  as  it  does,  a 
distinct  influence  upon  the  severity  of  the  disease  complex,  (see  table,  page 
215)  may  be  in  the  nature  of  a  vasomotor  unbalance  which  serves  as  the 
basis  of  all  its  manifestations  (Moro)  and  is,  in  certain  cases,  of  inherited  or 
congenital  quality.  In  others  the  neurosis  of  the  patient  is  an  acquired 
feature  and  often  results  from  errors  in  training,  for  the  indulgence  of  which 
the  exudative  diathesis,  with  its  repeated  exhibitions  of  ill  health,  has  given 
ample  opportunity. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  221 

ARTHRITISM  IN  CHILDHOOD 

Quite  recently  and  contrary  to  preexisting  beliefs,  a  relationship  between 
the  exudative  diathesis  of  children  and  the  uric  acid  diathesis  of  adults,  is 
accepted  as  a  probability  in  view  of  the  demonstration  of  an  infantile  dis- 
turbance of  uric  acid  excretion.  (Kern,  Uffenheimer.)  The  condition  which 
forms  the  clinical  connecting  link  between  them  is  arthritism,  a  condition 
which  Comby  defines  as  an  hereditary  and  habitual  disturbance  of  nutri- 
tion. This  phenomenon  is  a  widely  distributed  one,  but  is  not  observed  in 
all  classes  of  society  and  in  all  places.  It  occurs  chiefly  in  the  well-to-do 
families  of  city  life,  among  the  hypercivilized  and  the  highly  intellectual 
of  the  people.  Very  few  cases  are  seen  in  the  free  dispensaries,  while  private 
practice  among  the  wealthy  furnishes  numerous  examples.  Homologous 
and  heterologous  types  of  hereditary  transmission  are  distinctly  recognized 
in  this  expression  of  disease.  According  to  Comby,  the  members  of  an 
individual  family  may  be  subject  to  diabetes,  gout,  obesity,  renal  calculi, 
migraine,  asthma,  and  the  various  neuropathies  and  psychopathies,  known 
as  the  group  of  Bouchard's  bradytrophy.  Even  though  the  beginning  of 
the  disease  may  be  traced  back  to  the  early  history  of  the  child,  most  of 
these  cases  are  first  recognized  at  school  age. 

The  habitus  of  these  children  is  variable.  A  distinct  division  into  the 
various  types,  such  as  the  anemic,  erethismic,  plethoric  and  obese,  is 
neither  possible  nor  practical.  Very  frequently  we  find  cases  representing 
successive  transitions,  or  mixed  cases,  or  even  those  in  whom  the  external 
habitus  does  not  differ  from  the  normal. 

As  we  have  already  said,  the  manifestations  of  the  exudative  diathesis 
are  very  numerous,  but  from  the  combination  of  symptomatic  elements 
extremely  variable  pictures  arise.  According  to  reports  in  the  French 
literature  these  manifestations  may  include  the  entire  symptom-complex 
of  the  inflammatory  diathesis  if  we  consider  that  this  is  not  confined  to  the 
fust  months  or  even  years  of  life,  excepting  as  to  such  incidents  as  sebor- 
rhcea,  intertrigo,  oradle-cap,  etc.  The  recurring  catarrhal  disorders  and  the 
nervous  conditions  connected  with  them  (see  table  page  215)  are  the  most 
conspicuous.  To  these  may  be  added  a  large  number  of  symptoms  of 
greater  or  less  note.  Definite  rises  of  temperature,  resembling  those  of 
malaria,  but  without  apparent  cause,  with  a  persistent  increase  of  the 
rectal  temperature  to  about  38°  C.  (100.4  F.)  especially  after  exercise; 
changes  of  color  in  the  face,  transient  erythemata,  cold  hands  and  feet, 
chilblains,  sweats,  fainting,  etc.;  tachycardia,  palpitation,  habitual  arhyth- 
mia,  cardiac  asthenia  and  dilatation,  diminished  blood-pressure,  accidental 
heart  murmur  and  venous  bruits;  affections  of  the  upper  air  passages, 
as  spasmodic  sneezing,  cough  and  hay  fever,  all  of  these  are  possible  fea- 
tures of  the  complex. 

Referring  to  the  intestinal  tract,  the  condition  invites  anorexia,  esopha- 
geal  spasm,  cardiospasm,  gastric  and  intestinal  atony,  indicated  by  clapo- 
tage  and  distension,  obstinate  habitual  constipation,  intestinal  colic, 
muco-membranous  enteritis,  appendicitis,  nervous  cyclic  vomiting,  with  or 


222  TEXT-BOOK  OF  PEDIATRICS 

without  acetonemia,  occurring  as  car-sickness  or  as  a  consequence  of  psychic 
excitement  or  responsively  to  other  marked  irritation,  and  sometimes  in  the 
early  morning  when  the  stomach  is  empty.10  The  genito-urinary  system, 
also,  may  be  affected  ard  present  such  symptoms  as  cloudiness  of  the  freshly 
voided  urine,  with  non-organized  sediments,  (uric  acid,  urates,  phosphates 
and  oxalates);  intermittent  albuminuria  of  the  orthostatic  type;  polyuria, 
cystic  spasms,  dysuria,  diurnal  and  nocturnal  enuresis,  cystitis  and  ure- 
thritis,  balanitis,  with  erections  and  masturbation. 

As  nervous  phenomena  of  the  diathesis,  may  be  numbered  pavor  noc- 
turnus,  choreic  restlessness,  tics,  the  f acialis  phenomenon,  severe  typical  and 
atypical  migraine,  neuralgias,  rheumatoid  pains,  arthralgias  (from  which 
the  rather  unfortunate  term  arthritism  has  been  suggested),  osteal- 
gia  without  objective  cause,  unusual  flaccidity  of  the  muscles  and  pos- 
tural errors. 

In  the  hyperplasia  of  the  lymphatic  system  the  most  important  involve- 
ment is  that  of  the  faucial  and  pharyngeal  tonsils  with  its  common  sequelae. 
Next  in  consequence  comes  the  hyperplasia  of  the  bronchial  and  mediastinal 
lymph  nodes  causing  anomalies  in  the  respiratory  sounds,  areas  of  pul- 
monary dulness  confirmed  by  Roentgen  shadows,  and  signs  of  varying 
compression  especially  upon  bending  back  the  head.  The  spleen  may  be 
palpable  and  occasionally  the  lymph  nodes  in  the  neck  and  in  the  joint 
flexures  become  markedly  enlarged. 

These  and  companion  symptoms  may  appear  singly  or  in  variegated 
grouping.  They  may  appear  at  more  or  less  regular  intervals  in  varying 
degrees  of  severity,  becoming  progressively  more  and  more  definite.  Indi- 
vidual manifestations  have  often  been  looked  upon  as  separate  and  distinct 
diseases  and  their  appearance  in  orderly  succession  has  been  regarded  as 
accidental.  The  more  carefully,  however,  the  history  of  the  patient  and 
that  of  his  immediate  family  is  studied,  the  longer  the  observation  of  the 
patient  is  continued  and  the  better  the  observer  becomes  acquainted  with 
his  conditions,  the  more  readily  will  the  relation  of  the  individual  patho- 
logic elements  to  the  special  predisposition  or  diathesis  be  recognized. 

Even  though  rarely  fatal,  such  manifestations  of  the  disease  as  hyper  - 

10  The  acetonemic  vomiting,  a  very  characteristic  symptom  of  a  combined  neuropathic 
and  metabolic  disturbance,  occurs  in  the  following  manner.  Children,  especially  boys, 
previously  affected  by  atony  of  the  stomach  and  intestines,  with  habitual  obstipation, 
become  ill  every  few  weeks  with  frequent,  violent  and  uncontrollable  vomiting.  This 
may  follow  some  active  voluntary  exercise  or  may  be  entirely  spontaneous  or  independent 
of  any  exciting  cause.  The  attacks  may  last  for  several  days,  during  which  time  all  food 
is  ejected.  The  vomitus  may  be  bile-stained  and  bloody.  The  accompanying  exhaustion 
may  become  alarming,  but  the  patient  usually  recovers  very  quickly  after  the  vomiting 
has  ceased.  During  the  attacks,  there  is  not  only  acetonuria,  but  evident  excretion  of 
acetone  from  the  lungs.  The  presence  of  acetoacetic  acid,  and  of  /3-oxybutyric  acid  in 
the  urine  and  expired  air  may  further  indicate  the  acidosis.  Icterus  and  enlargement  of 
the  liver,  with  elevations  of  temperature  may  be  noted.  Apparently  the  condition  is  a 
cataclymic  eruption  ot  an  otherwise  more  or  less  latent  disturbance  of  metabolism. 
According  to  Hecker,  it  is  an  interference  with  the  catabolism  of  fat  due  to  the  hypoplasia 
of  the  lymphatic  system.  The  eruption  is  seemingly  brought  on  by  nervous  influences. 
Suggestive  treatment  is  occasionally  effectual.  The  writer  prefers  an  active  catharsis 
once  a  month,  with  the  daily  use  of  calcium  chloride  or  of  alkalies,  with  physiologically 
alkaline  food,  for  a  long  period. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  223 

pyrexia  without  objective  cause,  succeeding  an  equally  causeless  collapse, 
acetonemia,  paroxysmal  tachycardia,  pavor  nocturnus,  colic,  enteritis, 
migraine,  fainting,  skin  eruptions  are,  to  say  the  least,  very  distressing  and 
unpleasant  complications. 

Often,  as  a  result,  the  child  is  unable  to  attend  school  and  the  diathesis 
is  harmful  from  the  social  standpoint  while  such  injuries  as  impairment 
of  hearing,  aprosexia  in  adenoid  disease,  enuresis,  masturbation,  etc. —  have 
an  ethical  or  moral  bearing. 

Treatment. — The  treatment  of  the  exudative  diatheses  cannot,  perhaps, 
be  directed  against  the  fault  in  the  germ  or  the  resulting  perversions  of 
metabolism,  but  only  against  those  certain  external  influences  which  excite 
its  manifestations,  such  as  the  frequent  intercurrent  infections  and  those 
comph' eating  structural  abnormalities  and  functional  disturbances  which 
aggravate  the  initial  error. 

The  secondary  infections  which,  as  Czerny  believed,  may  convert  the 
relatively  innocuous  primary  manifestations  of  the  diathesis  into  severe 
forms  of  disease,  may  be  combated  preventively  by  reducing  both  the 
predisposition  to  attack  and  the  opportunity  of  infection.  In  the  accom- 
plishment of  this  first  aim,  dietetic  management  has  proved  useful  in  a 
purely  empirical  way.  Procedures  which  serve  to  remove  the  excess  of 
fluid  from  the  tissues,  if  promptly  applied,  will  have  a  favorable  influence 
upon  the  hyperplasia  of  the  tonsils,  etc.,  and  should  take,  therefore,  a  very 
important  place  in  the  treatment. 

After  the  first  two  years,  a  largely  vegetable  dietary  is  to  be  recom- 
mended, supplemented  with  only  a  small  quantity  of  meat  and  but  one- 
fourth  to  one-half  a  litre  of  milk  a  day.  Eggs,  cream,  butter  and  sugar  are 
not  well  borne.  During  the  first  two  years,  the  smallest  possible  quantity  of 
milk  compatible  with  gradual  gains  in  weight  and  general  development 
should  be  given.  Human  milk  is  to  be  preferred,  but  with  any  form  of 
feeding  the  number  of  meals  and  the  length  of  the  individual  feeding  must 
be  curtailed.  If,  in  spite  of  these  measures,  a  child  is  inclined  to  grow  too 
fat,  carbohydrates,  broths  and  vegetables  may  be  substituted  for  a  part  of 
the  milk  even  during  the  latter  half  of  the  first  year.  At  a  year  and  a  half 
the  child  may  be  put  upon  the  diet  of  more  advanced  childhood. 

A  poor  development  of  the  breast-fed  infant  with  exudative  tendencies 
is  often  improved  by  a  change  to  mixed  feeding,  in  which  such  additions  as 
buttermilk,  gruels  or  malt  soup  are  desirable. 

An  example  of  a  menu  for  a  child  of  two  years,  as  advised  by  Czerny, 
follows: 

Breakfast:  Milk,  diluted  with  hot  water,  and  toast  without  butter; 
followed  at  10  A.  M.  by  raw  fruit. 

Luncheon:  A  thick  soup,  preferably  of  well-cooked  legumes;  finely 
divided  meat;  and  such  fresh  vegetables  as  spinach,  carrots,  kohl-rabi, 
cauliflower,  lettuce  or  string  beans. 

At  4  p.  M.    Diluted  milk  with  toast  or  cake. 

Supper:  Finely  divided  meat,  with  bread,  potato  or  rice,  and  a  very 
little  butter.  Weak  tea,  or  water  with  fruit  juices,  may  be  added. 


224  TEXT-BOOK  OF  PEDIATRICS 

The  most  efficient  method  of  lessening  the  opportunities  of  infection  to  a 
minimum  is  to  keep  the  child,  whether  in  the  country  or  in  the  city's 
suburbs,  in  a  place  where  the  air  is  free  from  dust  and  smoke.  The  summer 
vacation  spent  in  climatically  favorable  places, avoiding  hotels  and  sanatoria 
should  be  extended  as  long  as  possible.  The  little  patient  should  be  kept 
away  from  disease  carriers,  such  as  adults  with  catarrhal  infections  or  so- 
called  colds.  Chilling  should  be  avoided  by  out-of-door  exercise.  Attempts 
at  hardening  or  accustoming  the  child  to  infective  agencies  are  useless. 

Finally,  great  emphasis  must  be  put  upon  the  importance  of  psychic 
treatment  in  cases  which  show  signs  of  present  or  impending  nervous  dis- 
turbances. This  consists  in  seeking  to  withdraw  the  attention  of  the 
patient  from  his  physical  ills  by  systematized  play  or  occupation,  by  the 
parental  avoidance  of  anxiety  and  excessive  care  and  by  abstaining  from 
medication  and  sanatorial  treatment.  The  child  should  be  protected  from 
association  with  neurotic  or  mentally  unbalanced  persons.  In  certain  cases 
it  may  be  necessary  to  remove  the  patient  from  the  home  and  to  change 
his  entire  mode  of  living  and  training. 

The  main  indications  in  the  treatment  of  arthritism  are  similar,  for  this 
disposition  frequently,  although  not  always,  arises  from  the  inflammatory 
diathesis  and,  as  a  result  of  harmful  psychic  influences  gradually  tends  to  a 
more  and  more  neuro-psychopathic  type. 

In  these  phases  of  the  condition  the  largely  vegetable  dietary  recom- 
mended may  occasionally  exert,  a  favorable  influence  upon  the  viscero- 
somatic  symptoms,  but  will  have  a  less  definite  or  indeterminable  effect 
upon  the  stated  neuro-f unction al  disturbances.  Tonic  remedies,  whether 
foods  or  medicines,  iron,  arsenic,  quinine — in  fact,  practically  all  drugs 
that  have  been  tried,  are  useless  and  even  harmful,  for  their  use  tends  to 
fasten  the  child's  attention  upon  its  ailments.  For  the  same  reason,  all 
highly  artificial  measures  as  hydrotherapeutic  and  other  physical  treatments 
in  sanatoria  or  elsewhere  should  be  avoided.  It  is  better  to  place  the  child 
in  natural  surroundings,  adapted  to  its  physical  and  mental  development, 
which  will  approach  as  nearly  as  may  be  to  "the  simple  life. " 

Certain  symptoms,  of  course,  require  special  methods  of  treatment. 
These  should  be  brought  into  accord,  however,  as  nearly  as  possible  with  the 
essential  principles  of  management  already  laid  down. 

As  the  detail  given  may  suggest,  the  entire  treatment  proposed  ap- 
proaches at  many  points,  the  methods  applied  in  the  so-called  "nature 
cures."  Nevertheless,  the  aim  of  this  counsel  has  been  to  avoid  the  injuries 
so  commonly  incurred  in  these  systems;  as  the  sleeping  in  large  wards,  the 
entire  deprivation  of  meat,  the  forced  cold  water  treatment  with  resulting 
chills,  etc. 

In  cases  of  the  status  lymphaticus,  the  danger  of  operative  shock  and  of 
serious  nervous  excitement,  as  that  attending  the  use  of  anesthetics,  or  the 
Roentgen  treatment,  or  even  the  administration  of  hot  and  cold  baths, 
should  be  emphasized;  while  the  special  risks  of  acute  infections  diseases,  as 
in  the  severe  toxic  form  of  scarlet  fever,  must  always  be  borne  in  mind  and 
the  patient  treated  with  more  than  ordinary  precautions. 


THE  BLOOD  AND  BLOOD-FORMING  ORGANS  225 

Formerly,  great  difficulty  was  encountered  in  the  differentiation  of  the 
status  lymphaticus  from  scrofula.  The  two  were  repeatedly  but  mistakenly 
associated  and,  as  a  result,  progress  of  pathogenic  and  clinical  research  was 
materially  impeded.  It  is  true  that  careful  observers,  in  their  bedside 
investigations,  had  attempted,  long  ago,  to  make  a  definite  distinction 
between  these  conditions;  but  it  was  Koch's  anaphylactic  methods  of 
diagnosis  and  the  safe  and  handy  modifications  proposed  by  v.  Pirquet  and 
Moro  which  first  made  their  positive  separation  possible.  Hence  we  have 
come  to  the  acceptance  of  the  view  that  scrofula  is  that  form  of  tuberculosis 
in  childhood  which  occurs  in  cases  of  lymphatism  (Moro,  Escherich). 


15 


APPENDIX 

PATHOLOGY  OF  THE  GLANDS  OF  INTERNAL 
SECRETION 

A.  PATHOLOGY  OF  THE  THYROID 

IN  the  consideration  of  the  pathology  of  the  thyroid  body  the  greatest 
clinical  interest  attaches  to  those  disease-pictures  which  are  proven  to  arise 
from  functional  disturbances  of  the  organ.  These  disturbances  may  be 
due,  on  the  one  hand,  to  complete  or  partial  absence  of  the  gland  or  to 
qualitative  changes  in  its  activity,  described  as  athyreosis,  hypothyreosis 
and  dysthyreosis,  and,  on  the  other  hand,  to  a  pathologic  increase  of  its 
functional  activity,  known  as  hyperthyreosis.  For  the  general  pathology  of 
these  conditions  we  must  refer  the  reader  to  text-books  of  internal  medicine. 
However,  the  point  of  especial  interest  to  the  podiatrist  is  that  during  intra- 
uterine  life,  and  probably  during  early  infancy,  the  lack  of  the  thyroid  gland 
in  the  child  may  be  met  by  the  increased  activity  of  the  maternal  gland. 
The  active  principles  of  the  thyroid  secretion  undoubtedly  pass  through  the 
placenta  and,  perhaps,  through  the  mammary  gland,  and  thus  reach  the 
infant  organism.  Therefore,  fatal  disease  due  to  absence  of  the  thyroid  gland 
is  never  seen.  This  is  significant  since  the  young  and  growing  organism  is 
especially  susceptible  to  injury  from  disturbances  of  the  functional  activity 
of  the  thyroid.  The  group  injuries  due  to  hypothyreosis  are  seen  only  in 
childhood.  In  these  conditions  perfect  therapeutic  results  can  be  obtained 
only  when  the  status  is  recognized  and  treated  in  early  life. 

HYPOTHYREOSIS;  ATHYREOSIS 

These  conditions  may  be  conveniently  classified  in  accordance  with 
their  anatomic  and  etiologic  causes. 

1.  Hypothyroidism  may  be  caused  by  anomalies  of  structure,  resulting 
in  complete  absence  of  true  thyroid  tissue.     The  anatomic  conception  of 
this  complete  thyroid  aplasia,  the  congenital  athyreosis,  coincides  com- 
pletely with  the  clinical  picture  of  congenital  myxedema. 

Cystic  formations  are  found  occupying  the  place  of  the  lateral  thyroid 
germ  centres  and  developing  epithelioid  tumors  at  the  base  of  the  tongue. 
The  epithelial  cells  persist  in  this  type.  The  condition  is  one  of  actual 
primary  aplasia  of  the  gland  with  an  absence  of  its  arteries. 

Short  of  total  aplasia  of  the  gland  we  may  have  hypoplasia  and 
congenital  insufficiency,  which  lead  to  partial  degrees  of  congenital 
hypothyroidea. 

2.  Hypothyreosis  may  also  result  from  a  more  or  less  extensive  degener- 
ation of  the  gland  in  extra-uterine  life.    This  may  take  the  form  of  either  a 
primary  atrophy  or  a  goitre-like  dystrophy;  in  either  of  which  forms  the 
active  glandular  tissue  may  entirely  disappear.     According  to  Wieland, 

226 


PATHOLOGY  OF  GLANDS  OF  INTERNAL  SECRETION    227 

this  is  a  condition  affecting  the  germinally  weak  gland  in  what  may  be 
called  a  " h3rpothyroidic  diathesis." 

In  this  event,  the  parathyroid  bodies  may  be  included  in  the  degenera- 
tive process.  For  the  sequelae  of  this  involvement  the  reader  is  referred  to  the 
Chapter  on  Spasmophilia  (Tetany). 

Such  thyroid  degenerations  are  observed,  (a)  in  certain  localities  where 
they  appear  as  an  endemic  cretinism,  arising  from  injuries  common  to  the 
region,  of  the  nature  of  which  but  little  is  known;  and  (6)  as  entirely  spo- 
radic cases,  presenting  varying  conditions  of  the  thyroid,  but  resulting  in  an 
acquired  form  of  infantile  myxedema.  Either  of  these  types  is  frequently 
seen  in  abortive  forms. 

3.  Finally,  hypothyreosis  may  be  caused  by  the  partial  or  complete 
surgical  removal  -of  the  gland  which  results  in  an  operative  myxedema, 
(cachexia  thyreopriva).  This  condition  is  of  great  interest  from  an  experi- 
mental standpoint,  but  may  no  longer  be  considered  clinically  interesting. 

All  of  these  forms  of  a-  or  hypothyreosis  share  the  group  of  symptoms 
which  constitue  the  phenomena  of  absence,  relative  or  complete,  of  the 
function  of  the  thyroid  gland.  Their  clinical  relationship  is  therefore  a  very 
broad  one  and  their  differentiation  depends  primarily  upon  the  demon- 
stration of  the  etiologic  factor  in  each  case.  Certain  signs,  such  as  the  dis- 
turbance of  dentition,  are,  of  course,  clearly  manifest  when  the  functional 
activity  of  the  gland  has  been  wanting  from  the  earliest  postnatal 
period ;  while  others  appear  only  after  the  condition  has  existed  for  years.  It 
is  quite  probable  that  in  cretinism  there  are  injuries  to  other  and  possibly 
intracranial  organs  besides  those  which  have  led  to  the  disturbance  of 
thyroid  function. 

GENERAL  SYMPTOMS  AND  THEIR  CAUSES 

1.  Affections  of  the  Skeleton. — These  are  among  the  earliest  and  most 
constant  of  symptoms.  They  arise  from  a  disturbance  of  both  the  endo- 
chondral  and  periostea!  growth,  with  atrophy  of  the  bone  and  the  blood- 
forming  marrow. 

The  cartilage  formation  at  the  epiphyses,  the  extension  of  the  marrow 
capillaries  into  the  cartilage  cells,  the  resorption  and  to  a  degree  the  appo- 
sition of  the  bony  tissue  are  all  retarded.  The  process  of  calcification  is 
entirely  undisturbed.  The  result  is  the  development  of  sclerotic  bones  of 
normal  shape,  but  of  reduced  size.  It  is  apparent  that  the  hypothyroideal 
affections  of  bone  are,  in  some  respects,  the  precise  opposite  of  the  rickitic 
forms;  so  that  children  with  myxedema  never  give  definite  signs  of  rickets. 
The  epiphysial  centres  develop  late  or  are  entirely  absent,  while  their 
cartilaginous  structure  persists.  Longitudinal  growth  is  delayed  and  often 
continues  until  after  puberty.  The  Roentgen  picture  usually  shows  a 
characteristic  dark  shadow  at  the  diaphyses  representing  a  transverse 
lamella  of  bone  extending  toward  the  epiphysis.  (Figures  55  and  56.) 

Clinically,  the  disturbance  is  recognized  as  a  fairly  proportionate 
dwarfism,  which  becomes  more  and  more  pronounced;  by  changes  of  form 
due  to  anomalies  of  the  soft  tissue,  to  be  described  later;  by  a  depression  of 


228  TEXT-BOOK  OF  PEDIATRICS 

the  bridge  of  the  nose  not  appearing  as  an  initial  dystrophy, but  as  an  inhibi- 
tion of  growth  at  the  tribasilar  suture;  by  the  permanently  open  fontanelle 
and  cranial  sutures,  and  by  anomalies  of  dentition  and  of  teeth  formation. 
These  dental  anomalies  resemble  those  of  rickets.  The  closure  of  the  flat, 
low,  wide  cranium  may  be  delayed  even  longer  than  it  is  in  rickets,  but  the 
edges  of  the  bones  are  hard.  Fractures  heal  very  slowly  in  the  hypothyroidic. 

The  several  characteristics  of  the  cretinoid  skull  (after  Scholz),  are: 
orthocephalia,  platycephalia,  plagiocephalia,  platyrrhinia,  hypsicephalia, 
and  prognathus. 

Recently  this  disturbance  of  the  bony  growth  has  been  repeatedly  laid 
to  the  hypothyroideal  injury  of  the  blood-forming  marrow  (compare  rickets, 
scurvy,  etc.).  The  involvement  of  the  blood-forming  marrow  may  be 
regarded  as  the  cause  of  such  marked  evidences  of  anemia  as  the  pallid  or 
dull  yellow  skin,  the  oligocythemia,  oligochromemia  and  polynucleosis.  It 
may  be  held  responsible,  also,  for  the  hemorrhagic  diathesis  and  for  the 
enlargement  of  the  tonsils  and  of  the  lymph  nodes  which  such  cases  exhibit . 

2.  Changes  in  the  Skin  and  Mucous  Membranes. — As  a  result  of  a 
peculiar  redundancy  of  the  elements  of  the  subcutaneous  connective  tissue, 
the  nature  of  which  has  not  yet  been  determined,  the  skin,  at  certain  points, 
becomes  loosened  from  the  underlying  tissues  (cutis  laxd),  and  has  a  gela- 
tinous, doughy  or  slippery  feeling — the  myxedema  of  Ord.  True  edema, 
however,  with  complete  loss  of  elasticity  does  not  occur.  When  the  myx- 
edema disappears  the  skin  is  left  slack  and  wrinkled.  The  interference  with 
the  nutrition  of  the  epidermal  layers  causes  desquamation,  cracking  of  the 
finger-nails,  dryness  and  falling  of  the  hair;  the  lanugo,  however,  persisting. 
A  suppression  of  the  perspiration  also  results,  in  all  probability,  from  the 
dryness  and  the  reduced  electro-conductivity  of  the  skin. 

Similar  tumefaction  and  loosening  of  the  mucous  membranes  of  the  nose, 
pharynx,  middle-ear,  Eustachian  tubes,  and  especially  of  the  tongue  (mac- 
roglossia),  of  the  larynx,  the  eyelids  and  the  digestive  tract,  are  held 
responsible — although  not  always  convincingly — for  such  functional  dis- 
turbances as  mouth-breathing,  snoring  or  groaning  respiration,  hoarseness, 
impairment  of  hearing,  refusal  of  food  and  obstipation.  The  symptoms 
of  these  three  groupings  produce  very  characteristic  anomalies  in  the 
external  habitus  of  the  patient.  The  low,  flat  brow,  covered  by  wrinkled, 
hairy  skin;  the  flat  saddle-shaped  nose,  the  narrowed  aperture  of  the  swollen 
eyelids,  and  the  widely  gaping  mouth,  allowing  the  enlarged  tongue  to 
protrude  between  the  thick  and  almost  trunk-like  lips,  are  its  principal 
features.  There  is  often,  also,  a  double  chin;  the  ears  are  large  and  mal- 
formed ;  the  normal  contour  of  the  body,  moulded  upon  the  skeletal  lines,  is 
obscured  by  the  irregularly  thickened  soft  tissues.  This  certain  grotesque- 
ness  is  increased  by  spongy  skin-pads  formed  over  the  clavicles,  the  scapula 
and  the  hips  and  around  the  nipples.  The  limbs  are  cylindrical  and  pillar- 
like  and  the  fingers  and  toes  seem  shortened  and  stubby.  The  hand  re- 
sembles the  paw  of  a  mole.  The  abdomen  is  greatly  distended  »nd,  in 
younger  children,  is  frequently  and  further  deformed  by  an  umbilical  hernia. 


PATHOLOGY  OF  GLANDS  OF  INTERNAL  SECRETION  229 

3.  Psychic  Anomalies. — The  mental  development  is  arrested  at  a  very 
low  stage  or  rather  is  retrogressive  to  such  a  stage.  In  the  more  severe 
cases,  the  intellectual  capacity  of  the  patient  is  less  than  that  of  intelligent 
animals  (the  vegetative  man  of  Kocher).  The  mental  aberration  is  always 
of  the  characteristically  anergic  form.  The  child  is  uncleanly  and  drowsy; 
it  lies  for  days  without  reacting  to  sensory  impressions,  its  gaze  apatheti- 
cally fixed,  its  movements  automatically  responsive  when  forced.  It  roars 
when  hungry  or  in  pain.  Cases  of  lesser  severity  are  unable  to  fix  their 
attention,  to  recognize  objects  or  to  speak.  In  mild  forms  there  is  observed 


I 


I. __ 

FIG.  55. — Hand  of  a  six-year-old   girl  with  congenital  FIG.    56. — Hand    of    normal    six-year-old 

athyreosis.     Height  72  cm.  (28.8  fnches.)     Thick  sclerotic  child  for  comparison.    (Children's  Hospital, 

bones.     All    the    epiphysial  centres    of    ossification    but  Zurich,  Prof.  E.  Feer.1 
one  small  one  in  the  wrist   which    appeared  after  treat- 
ment with  thyroid  extract,  are  lacking. 

only  a  certain  weakness  of  the  intellect  and  memory,  an  inability  to  concen- 
trate attention  and  a  mental  dulness.  In  such  a  case  the  timidity,  the  cre- 
tinoid  demeanor,  the  gait,  the  grimaces,  the  inarticulate  sounds,  and  the 
dull,  morose,  animal-like  physiognomy  of  the  child  may  lead  one  upon  super- 
ficial acquaintance  to  under-estimate  its  actual  mental  ability.  The  delayed 
development  of  child 's  static  functions,  as  in  the  matter  of  sitting,  standing 
or  walking,  is,  in  part,  due  to  these  psychic  disturbances. 

There  is  still  much  diversity  of  opinion  as  to  the  organic  cause  of  these 
mental  perversions.  Severe  affections  of  the  auditory  apparatus,  both  of 
peripheral  and  labyrinthine  origin,  and  to  the  extent  of  deaf-mutism,  and  of 


230 


TEXT-BOOK  OF  PEDIATRICS 


the  tubal  and  middle  ear  tissues  incident  to  adenoids  are  often  concerned 
in  its  etiology. 

4.  Changes  in  Metabolism. — These  changes  consist  in  a  slowing  of  the 
metabolism,  particularly  in  the  field  of  protein,  water  and  salt  interchanges. 
The  consumption  of  oxygen  may  be  reduced  to  one-half  normal.  It  is 
supposed  that  the  low  average  body  temperature,  ranging  l°-2°  C.  below 
normal,  and  the  tendency  to  obesity  are  connected  with  this  slow  metab- 
olism. As  a  result  of  the  reduction  of  the  katabolic  processes  there  is  a  tend- 
ency to  nitrogen  and  phosphorus  retention.  As  a  further  result,  the  patient 


FIG.  57. — Three-year-old  child  with  aplasia  of  the 
thyroid  and  congenital  myxedema.  (University 
Children's  Hospital,  Munich,  Prof.  vonPfaundler.) 


FIG.  58. — Endemic  cretin  from 
the  Odenwald. 


can  maintain  weight  upon  quantities  of  food  which  would  be  altogether 
insufficient  for  the  normal  child  of  the  same  age.  The  limit  of  assimi- 
lation for  dextrose  is  raised. 

5.  Affections  of  the  Muscles. — The  musculature  is  usually  flaccid,  pale 
and  wanting  in  power.  It  is  said  also,  to  be  microscopically  changed.  At 
the  same  time  it  may  be  of  large  bulk  and  even  pseudohypertrophic.  Slow 
movements,  delayed  static  functions,  a  dragging  gait  with  equinus  and 
bended  kneee,  a  flattening  of  the  head  of  the  femur,  double-jointedness, 
lordosis,  abdominal  distension,  severe  obstipation,  diastasis  of  the  recti, 
umbilical  or  inguinal  hernia  and,  probably,  cardiac  weakness  with  small 
labile  pulse,  cold  mottled  skin  and  a  tendency  to  cardiac  asthma,  may  all  be 


related  to  this  muscular  impairment.    In  some  cases  one  finds  on  the  other 
hand,  a  large  and  firm  body  musculature. 

6.  Disturbances  of  Sexual  Development. — In  the  hypothyreoses, 
hypoplasias  of  the  germinal  organs  and  of  the  external  genitalia  are  found. 
Partial  development  of  sexual  functions,  a  lack  of  the  secondary  sexual  char- 
acteristics, postponed  puberty,  genital  infantilism  and  menorrhagia  follow. 


1.  Congenital  myxedema  is  more  common  among  females.     Neither 
hereditary  factors  nor  any  other  recognizable  causes  enter  into  considera- 
tion in  the  hypothyreoses.   The  first  indications 

of  the  deficiency,  apathy,  delayed  growth,  and 
the  changes  in  the  skin  and  the  mucous  mem- 
bianes,  are  usually  noticed  during  the  first  week 
in  artificially-fed  infants  and  after  the  first 
month  in  breast-fed  babies.  The  structural 
changes  in  the  skeletal  framework  originate  at 
birth.  The  entire  symptom-complex  develops 
rapidly,  as  a  rule,  to  the  point  of  severity. 
Most  of  the  cases  die  during  their  first  years 
and  only  rarely  do  they  pass  into  the  second 
decade.  The  entire  absence  of  the  thyroid 
gland  may  hardly  ever  be  demonstrated  clini- 
cally on  account  of  the  changes  in  the  skin  and 
in  the  muscle  topography. 

2.  (A)  Endemic  cretinism  affects  man  and 
animals  alike  in  the  so-called  goitre  districts 
of  certain  mountainous    countries  of  Europe. 
These  districts  lie  particularly  in  the  Swiss  Alps 
and  the  Black  Forest  but  are  found  in  other 
parts  of  the  world.    The  disease  is  somewhat 
more  common  among  males.    Hereditary  and 
familial    influences    are    in    part    responsible. 
Presumably  they  consist  merely  in  a  peculiar 
congenital  lack  of  resistance  of  the  gland  to 
injurious  influences.     A  degree  of  significance 

appears  to  attach  to  the  family  residence  in  a  dangerous  locality. 
Children  brought  from  other  and  healthy  districts  into  such  localities 
are  frequently  affected  at  an  early  age;  while  children  of  families  af- 
fected with  cretinism  who  leave  the  infected  district  in  early  childhood  or 
are  born  in  other  parts,  often  recover  or  remain  healthy.  The  cretin  dis- 
tricts are  not  confined  to  mountainous  regions  but  also  exist  in  localities 
marked  by  the  emergence  of  certain  geological  strata  of  the  earth 's  surface, 
or  lie  along  the  lower  reaches  of  rivers  which  flow  through  such  formations. 
There  are  many  indications  that  the  noxious  agent  is  carried  in  unboiled 
drinking  water.  The  hypothesis  that  the  mineral  substances,  taken  up  by 
the  water  from  these  rocky  foundations,  may  exert  in  young  persons  a 


FIG.  59. — Six-yearK>ld  boy, 
sporadic  cretinism. 


232 


TEXT-BOOK  OF  PEDIATRICS 


damaging  or  degenerative  influence  upon  the  thyroid  gland  (Author,  1907), 
is  quite  compatible  with  the  known  facts.  The  writer  considers  the  attempts 

that  have  been  made  to  demonstrate  in- 
fectious or  contagious  influences  in  the 
causation  of  the  disease  as  complete  failures 
or  very  unsatisfactory  in  results. 

Clinically  the  thyroid  is  found  to  be 
enlarged  in  about  sixty  per  cent,  of  cretins. 
Structurally,  these  cases  show  a  variety  of 
goitrous  degenerations,  cystic,  parenchy- 
matous,  hemorrhagic  and,  more  rarely, 
atrophic  in  type.  Portions  of  the  glandular 
tissue  may  remain  anatomically  intact  and 
are,  perhaps,  functionally  active. 

The  symptoms  of  endemic  cretinism 
appear  comparatively  late.  Usually,  the 
disease  may  be  recognized  definitely  only 
by  the  fifth  or  sixth  year,  or  even  later: 
The  disease-picture  becomes  very  gradually 
definite  and  hardly  ever  reaches  its  extreme 
development  during  childhood.  A  constant 
qualitative  difference  of  the  entire  symp- 


FIG.  60. — Twelve-month-old  girl 
with  myxedema. 

torn-complex  from  that  of  other 
hypothyreoses  can  hardly  be  said, 
however,  to  exist.  Besides  the 
signs  of  hypothyroidism  one  finds 
incidentally  those  of  hypogeni- 
talism  and  hypopituitarism. 

2.  (I?)  Acquired  infantile  myx- 
edema is  charged  to  various  acute 
diseases  of  the  gland  and  differs 
from  cretinism  chiefly  in  the  fact 
of  its  sporadic  occurrence. 

The  abortive  forms  of  hypo- 
thyreosis  are  of  special  interest 
to  the  physician.  They  may  de- 
pend initially  upon  congenital 
causes,  such  as  an  actual  hypo- 
plasia,  an  arrested  development 
or  a  functional  inadequacy  of  the 
gland.  They  may  be  a  manifes- 
tation of  hereditary  degeneracy,  due  to  alcoholism,  lues,  or  some  cachexia 
in  the  parent.  They  may  depend  upon  injury  acquired  in  some  cretinic 


Fio.  61. — Three  and  one-quarter-year-old  girl  with 
slight  manifestations  of  myxedema,  height  SO.  5  cm. 
(32.2  inches),  anterior  fontanelle  patent,  8  incisors, 
cannot  stand  and  kyphosis  on  sitting.  (Children's 
Hospital,  Heidelberg,  Prof.  E.  Feer.) 


PATHOLOGY  OF  GLANDS  OF  INTERNAL  SECRETION  233 


district  or  at  large.  Etiologically,  in  these  abortive  types,  the  clinical  ex- 
amination of  the  thyroid  is  of  little  value  and  the  findings  are  variable. 

Usually  the  psychic  symptoms,  as,  for  instance,  voice  changes,  depre- 
ciation of  mental  ability,  etc.,  are  not  definite.  The  somatic  picture  is 
confined  essentially  to  dwarfism,  to  disturbances  of  dentition,  to  a  slightly 
myxedematous,  dry  and  irritable  skin,  to  the  cretinoid,  care-worn  physiog- 
nomy and  to  the  general  demeanor.  The  disease  may  be  characterized, 
also,  by  such  functional  disturbances  as  chills,  anhydrosis,  awkwardness 
of  gait,  enuresis,  obstipation,  monotony  of  speech,  and  mental  inefficiency. 
The  Roentgen  picture,  showing  the  delayed  ossification  and  the  transverse 
diaphyseal  plates,  may  support  a 
diagnosis  which  will  receive  even 
greater  encouragement  from  the 
therapeutic  results  to  be  reviewed. 

INFANTILISM 

Clinically,  these  cases,  may  be 
correctly  included  in  the  sympto- 
matic group  belonging  to  the  condi- 
tion of  so-called  infantilism.1 

Under  the  term  infantilism  are 
included  conditions  of  widely  vary- 
ing etiology,  in  which  the  physical 
and  mental  development,  relative  to 
the  actual  age,  present  an  abnor- 
mally youthful  habitus.  Some 
authors  distinguish  two  varieties  of 
infantilism  arising  from  insufficiency 
of  the  thyroid  function.  Of  these,  the 
Brissand-Hertogh  type  has  true  hy  po- 
thyroideal  manifestations.  The  type 
of  Lorrain,  characterized  by  delayed 
growth  in  height,  with  a  symmetry 
of  proportions,  slender  bones,  grace- 
ful extremities,  small  narrow  head 

and  girlish  appearance,  deviates  markedly  from  the  former  and  its  fit  plac- 
ing in  this  class  is  very  questionable.  In  this  type,  it  would  seem,  rather, 
that  a  functional  lack  in  other  glands,  as  the  ovaries,  the  suprarenals,  the 
thymus  or  the  pancreas,  or  that  injuries  due  to  improper  feeding,  early  infec- 
tions, intoxications  or  organic  diseases,  may  enter  into  the  causation  (Anton) . 

The  abortive  infantile  hypothyreoses  are  characteristically  benign  and 
tend  to  spontaneous  recovery. 

TREATMENT 

The  treatment  of  the  hypothyreoses  is  based  upon  physiologic  substitu- 
tion.   The  reliability  and  applicability  of  this  method,  in  all  forms  of  the 

1  The  histologic  findings  in  the  osseous  system  resemble,  of  course,  a  senile  marasmus 
rather  than  an  infantile  dyscrasia  (Dieterle). 


FIG.  62. — Two-year-old    boy    with    mpngoloid 
idiocy.    Characteristic  laxity  of  the  joints. 


234  TEXT-BOOK  OF  PEDIATRICS 

disease  in  early  childhood,  is  now  generally  accepted.  Doubtless,  the 
simplest  and  most  rational  procedure  would  be  the  implantation  of  a  thyroid 
gland  of  the  same  species  at  any  suitable  place  in  the  body  of  the  patient, 
provided  that  such  a  transplanted  organ  could  maintain  its  functional 
activity.  This  has  been  attempted  in  a  number  of  instances  but,  according 
to  report,  it  has  seemed  impossible  to  keep  the  transplanted  organ  duly 
active.  Under  the  law  of  biologic  specificity,  it  would  not  appear  possible. 
Fortunately  the  fairly  thermostable  active  principles  of  the  animal  thyroid 
are  transferable  and  may  even  be  absorbed  through  the  digestive  tract.  It 
is  deemed  best  to  feed  the  thyroid  gland  of  food  animals.  This  is  given  in 
fresh  raw  form,  finely  divided,  and  prepared  with  butter,  eggs,  and  spices. 
The  glands  of  sheep  are  most  commonly  used,  but  those  of  cattle  or 
hogs  may  be  employed.  Care  should  be  taken  to  see  that  the  animal  from 
which  the  gland  is  taken  is  healthy  and  that  such  other  organs  as  the 
thymus,  salivary  glands,  lymph  nodes,  or  pancreas  are  not  substituted. 
One  or  two  pairs  of  sheep  glands  are  given  two  or  three  times  a  week. 

As  a  similar  substitute,  the  more  easily  obtained  pharmaceutical  prep- 
arations of  the  dried,  or  desiccated  or  extracted  thyroid  gland  are  recom- 
mended. Thyroxin,  the  active  principal  of  the  gland  may  be  used.  Other 
methods  of  administration,  as  by  subcutaneous  injection  or  enemata,  have 
been  discarded. 

The  results  of  this  treatment  are  usually  very  marked.  It  affects  all  the 
somatic  and  psychic  manifestations  of  hypothyreosis  at  once.  Improve- 
ment may  be  noted  within  a  few  days  and  may  lead  to  the  complete  disap- 
pearance of  the  symptoms.  Discontinuance  of  the  remedy  quite  naturally 
causes  a  remission.  Especially  favorable  results  are  seen  in  the  treatment  of 
congenital  and  acquired  myxedema,  but  benefit  is  had  even  in  endemic 
cretinism  among  young  patients.  The  average  of  results  of  the  treatment 
gathered  from  large  numbers  of  cases  would  probably  be  even  better  than  it 
is,  if  occasional  complicating  Diseases,  unrelated  to  the  hypothyreopis,  could 
be  excluded.  In  the  cretin,  the  treatment  does  not  affect  the  disturbances 
of  hearing  as  markedly  as  it  does  other  symptoms  and  the  unrelieved  deaf- 
ness may  hinder  mental  development. 

The  treatment  with  the  thyroid  gland  must  be  begun  very  carefully  and, 
at  first,  the  patient  must  be  scrupulously  watched.  Injuries  resulting  from 
excessive  doses  may  be  of  hyperthyroideal  nature,  such  as  restlessness, 
palpitation  of  the  heart,  cardiac  weakness,  flashes  of  heat,  perspiration  and 
vomiting,  or  they  maybe  of  a  toxic  character,  resembling  those  of  botulism 
or  meat  poisoning.  The  latter  accident  occurs  only  when  suspicious  pharma- 
ceutical preparations  are  used. 

GOITRE 

Congenital  and  acquired  hyperplasias,  or  rather  hypertrophies,  and 
strumous  degenerations  of  the  thyroid  gland  are  seen  quite  frequently  in 
certain  families  in  which  the  disease  prevails;  but  are  otherwise  quite  rare. 
Congenital  goitre  frequently  appears  to  be  caused,  in  large  part,  by  a 
vascular  congestion  of  the  organ;  and  with  suitable  treatment,  or  even 


PATHOLOGY  OF  GLANDS  OF  INTERNAL  SECRETION    235 


without  treatment,  often  disappears  rapidly.  In  other  cases,  parenchy- 
matous  overgrowth  and  the  formation  of  nodes  and  cysts  are  observed. 
In  the  former  event,  a  scleral  degeneration  with  hypothyreosis,  and  in  the 
latter  the  very  opposite  condition  may  constitute  the  permanent  injury. 
A  congenital  struma  may  spread  very  gradually  until  it  extends  to  the  lower 
jaw  and  may  occupy  the  entire  neck.  This  may  result  in  symptoms  of  com- 
pression of  the  esophagus,  with  reflex  vomiting;  of  the  cervical  vessels,  lead- 
ing to  cyanosis  and  edema;  and  particularly  of  the  soft  trachea,  causing 
dyspnoea,  stridor,  pulmonary  atelectases  and  broncho-pneumonia.  Fibrous 
goitres  surrounding  the  trachea  and  extending  downward  beneath  the  ster- 
num are  especially  dangerous,  but  are  for- 
tunately quite  uncommon. 

At  puberty  the  frequency  of  goitre  is 
again  marked  and  especially  in  girls.  In 
these  cases,  we  may  also  find  general  dis- 
turbances, due  to  an  excessive  secretion 
of  the  gland.  They  may  go  on  to  the 
development  of  Basedow's  disease.  Glands 
enlarged  by  degenerative  changes  may  fail 
to  give  symptoms  of  hyperthyreosis  (q.  v.), 
even  though  there  is  a  huge  goitre  present. 

Treatment. — The  greater  number  of 
strumata  in  children  react  favorably  to 
iodine  treatment  in  the  form  of  potassium 
iodide  given  internally,  0.1-0.5  gms.  (2-8 
grs.),  a  day;  or  to  the  external  application 
of  potassium  iodide  ointment  with  the 
addition  of  a  small  amount  of  iodine. 
Preparations  of  the  thyroid  gland  cannot  be  recommended  and  are,  in  fact, 
contraindicated.  The  vascular  strumata  of  the  new-born  should  be  treated 
with  applications  of  ice  alone. 

BASEDOW'S  DISEASE 

This  disease  is  rare  in  childhood  and  is  met  with,  but  little  more  fre- 
quently toward  puberty.  It  is  a  hyperthyreosis  of  unknown  etiology, 
characterized  by  a  rapid  and  demonstrable  increase  in  the  size  of  the  gland. 
Its  manifestations  and  treatment  in  the  child  are  the  same  as  in  the  adult. 

INFANTILE  BASEDOWOID  DISEASE 

Recently  this  term  has  been  applied  to  a  condition  found  by  Hochsinger 
in  one  case.  It  is  said  to  be  characterized  by  mild  ocular  symptoms,  resem- 
bling those  of  Bascdow 's  disease  by  tremor,  palpitation,  and  hyperhydrosis. 
This  condition  coexisted  with  true  epilepsy  and  yielded  to  treatment  with 
the  thyroid  gland. 

B.  PATHOLOGY  OF  THE  GERMINAL  ORGANS 
Hypogenitalism,  eunuchoidism,  dystrophia,  adiposo-genitalis,  are  terms 
applied  to  a  condition  resulting  from  perverted  interstitial  development  of 


FIG.  63. — Facial  expression  of  a  ten-year- 
old  boy  with  cretinoid  degeneration. 


236  TEXT-BOOK  OF  PEDIATRICS 

the  reproductive  glands.  It  resembles  the  status  which  follows  castration. 
Eunuchoid  individuals  are  tall  and  long-limbed  and  inclined  to  adipose 
deposits  over  the  lower  abdomen,  thighs  and  eyelids,  or  sometimes  to  general 
obesity.  The  development  of  the  secondary  sexual  characteristics  is  re- 
tarded and  poorly  achieved.  The  epiphysial  grooves  remain  open  for  a 
long  time  and  the  genitals  are  small.  Abdominal  or  inguinal  crypt orchidism 
is  common.  Eunuchoid  boys  (for  in  females  the  condition  is,  to  say  the  least 
rare),  are  remarkably  quiet,  unassuming  and  dependent.  The  condition  is 
most  frequently  recognized  at  puberty.  In  the  course  of  years  spontaneous 
recovery  may  occur.  Thyroid  treatment  is  useless. 

C.  PATHOLOGY  OF  THE  HYPOPHYSIS 

Hypopituitarism,  or  the  reduction  of  the  function  of  the  glandular 
portion  of  the  hypophysis,  may  obtain  in  later  childhood  as  a  result  of 
pathologic  changes  in  the  organ  itself,  or  in  the  neighboring  structures. 
Such  a  disturbance  is  associated  with  a  dystrophy  of  the  genitals  (hypophys- 
ial  form)  since  it  causes  a  retardation  of  the  development  of  the  inter- 
stitial and  generative  portions  of  these  organs.  Aside  from  the  obesity  or 
abnormal  distribution  of  the  fat  which  becomes  especially  marked  about  the 
thighs,  breast  and  hips,  the  small  genitals  and  the  failure  of  the  secondary 
sexual  characteristics  with  reduced  metabolism  and  increased  carbohydrate 
tolerance;  we  have  here  also  the  growth  anomalies  of  the  eunuchoid  type. 
This  is  characterized  by  the  great  height,  due  to  the  continued  growth  01  the 
long  bones  after  the  normal  period  for  the  attachment  of  the  epiphjrses 
which,  in  turn,  is  delayed  because  the  generative  organs  do  not  stimulate 
the  growth.  In  many  cases,  however,  a  disturbance  of  ossification  of  true 
pituitary  origin  counteracts  this  continued  growth.  The  pituitary  action 
here  is  to  delay  the  growth  of  the  centres  of  ossification  resulting  in  a  small 
child-like  body.  The  two  forms  of  genital  dystrophy  with  obesity  can 
further  be  distinguished  by  the  appearance  of  focal  brain  symptoms  or  by 
the  appearance  of  the  cella  turcica  in  the  radiogram. 

The  treatment  with  pituitary  extract  by  mouth  is  apparently  of  some 
benefit,  surgical  interference  and  Roentgen  treatment  of  doubtful  value. 

D.  DISTURBANCES  OF  GROWTH 

GENERAL   PHYSICAL  ANOMALIES  OCCURRING  WITHOUT  RECOGNIZED 

RELATION   TO  THE  HEMIC  GLANDS 

Chrondrodystrophia  (Kaufmann,  1892),  achondroplasia  (Parrot  1878), 
or  micromelia  chrondromalacia,  is  a  disease  of  the  fetal  cartilaginous  skele- 
ton. It  occurs  chiefly  in  females.  The  proliferation  of  the  cartilage  at  the 
junction  of  the  epiphysis  and  the  diaphyses,  which  represents  the  method  of 
longitudinal  growth  of  the  bones  performed  in  cartilage,  is  inadequate. 
On  the  contrary  the  calcification  and  ossification  of  the  shorter  cartilaginous 
shafts,  as  well  as  the  periosteal  ossification,  are  not  affected  or  proceed  even 
more  rapidly  than  usual.  The  end  result  is  seen  in  abnormally  short  and 
thick  bones  and  in  premature  synosteoses.  An  abnormal  strand  of  con- 
nective tissue  passing  from  the  periosteum  into  the  epiphysial-diaphyseal 


PATHOLOGY  OF  GLANDS  OF  INTERNAL  SECRETION    237 


boundary — the  characteristic  periosteal  lamella — causes  an  irregular  one- 
sided growth  and  results  in  the  decurvation  of  the  bone.  The  width  of  the 
cartilaginous  epiphyses  varies.  Occasionally  it  is  diminished;  again  it  may 
be  enlarged  to  a  mushroom-like  thickening,  represent  ing  both  the  hypoplastic 
and  the  hyperplastic  forms. 

The  clinical  picture  presents  a  micromelia,  determined  by  the  shortness 
of  the  limbs  and  accompanied  by  the  true  saddle-form  nose  caused  by 
synosteosis  of  the  tribasilaris.  The 
excess  of  fatty,  but  not  gelatinous 
skin  hangs  upon  the  short  limbs  in 
folds  and  wrinkles  like  trousers  or 
sleeves  that  are  too  large.  These 
appearances  are  often  mistaken  for 
the  myxedematous  cutis  laxa  and 
for  the  true  cretinoid  physiognomy. 
For  the  cranium  is  large,  the  neck 
heavy,  and  the  three  stub-pointed 
middle  fingers,  on  account  of  the 
union  of  their  basal  phalanges  and 
the  spreading  of  their  distal  pha- 
langes, form  the  characteristic 
trident  hand.  Other  malformations 
and  strumata  are  common  in  these 
cases.  The  children  who  survive 
attract  attention  because  of  their 
muscular  weakness,  double-jointed- 
ness,  the  delay  in  the  acquirement 
of  their  static  functions  and  in 
the  closure  of  the  fontanelles,  the 
rotatory  spasm  and  the  profuse 
sweating.  The  condition  is  some- 
times mistaken  for  rickets.  When 
the  patient  learns  to  walk  with  a 
characteristic  waddling  gate,  the 
preexisting  lumbar  kyphosis  becomes  a  lordosis  with  a  markedly  protrud- 
ing abdomen. 

His  intellectual  development  is  not  retarded  and  is  often  surprisingly 
good.  It  is  said  that  court  jesters  and  clowns  have  been  recruited  from 
this  class. 

Treatment  with  thyroid  preparations  is  generally  useless. 

OSTEOGENESIS  IMPERFECTA  (VROLIK) 

OSTEOPSATHYROSIS 

This  is  a  condition  of  deficient  endosteal  and  periosteal  ossification  with 
normal  formation  of  cartilage.  It  is  a  disturbance  of  osteoblastic  function. 
The  bones  grow  long,  but  are  thin  and  very  porotic.  On  this  account, 
numerous  so-called  spontaneous  fractures  occur  in  all  parts  of  the  skeleton. 


FIG.  64. — Eleven-year-old 


ith    Basedow's 


disease.    Improvement  after  ligature  of  the  arteries. 


238 


TEXT-BOOK  OF  PEDIATRICS 


both  in  fetal  and  postnatal  life.    These  fractures,  and  there  may  be  many, 
lead  to  malformations  and  to  a  shortening  of  the  extremities  (micromelia). 

The  development  of  numerous  calluses  may 
produce  a  conditon  which  resembles  an 
abnormal  thickening  of  the  bones.  In  the 
cranial  bones,  preformed  in  membrane,  large 
membranous  openings  may  persist.  (See 
Rickets.)  During  life,  the  Roentgen  picture 
shows  this  condition  very  plainly  (Fig.  66). 
Therapeutically,  phosphorus  and  cod-liver  oil 
to  prevent  rickets  has  been  found  valuable. 
Adrenalin  has  been  suggested.  No  doubt, 
fresh  air,  sun-baths  and  diet  must  all  be 
looked  after.  All  cases  in  which  the  diagnosis 
was  definitely  established  died  during  the 
first  year.  The  so-called  late  form  appear- 
ing in  older  children  appears  to  be  a  differ- 
ent disease. 

Mongolism-mongoloid  Idiocy. — (La  ng- 
don  Downs  1866.)  This  is  a  complex 
congenital  abnormality  which  suggests  a 


FIG.  65. — Month-old  child  with  chon- 
drodystrophy,  habitus  and  form  of  face, 
unusual  laxity  of  the  skin. 

"reversion  to  the  ape-man  type."  Its  struc- 
tural peculiarities  are  associated  with  serious 
impairment  of  mental  functions.  It  produces 
characteristic  changes  of  habitus  and  fre- 
quently implicates  to  a  great  extent  the 
functional  systems  of  the  affected  individual. 
According  to  Jodiche,  the  serum  of  a  mongo- 
loid  patient,  studied  by  Abderhalden's  sero- 
diagnostic  method,  showed  the  degeneration 
of  a  number  of  organs  and  especially,  of  the 
reproductive  glands.  Little  positive  knowledge 
of  its  etiology  has  been  acquired.  Varying 
indications  of  senility  in  the  mother  during 
pregnancy  seem  to  play  their  part.  The  dis- 
ease only  occurs  sporadically,  but  appears  in 
all  strata  of  society  and  in  all  countries.  It  has  seemingly  increased  in 
frequency  of  late  years.  The  sexes  are  affected  equally. 


FIG.  66, — Upper  extremity  of  a  new- 
born infant  with  osteopsathyrosis, 
multiple  fractures,  and  callous  for- 
mation. 


PATHOLOGY  OF  GLANDS  OF  INTERNAL  SECRETION    239 

The  habitus,  faintly  resembling  that  of  the  Mongolian,  is  the  most 
reliable  criterion  of  recognition.  It  is  marked  by  brachycephaly,  a  small 
saddle-shaped  nose,  slanting  eyes,  the  inner  canthus  being  lower  than  the 
outer,  with  narrow  lid  apertures,  epicanthus  (the  sickle-shaped,  vertical 
fold  of  skin  over  the  inner  canthus),  habitual  conjunctivitis  and  blepharitis, 
and  frequently  divergence  of  the  rather  prominent  eyeballs.  The  mouth 
gapes  and  is  constantly  salivated.  The  cheeks  and  chin  show  a  distinctly 
circumscribed  red  color,  suggestive  of  a  clown's  mask.  The  external  ear 
is  atavistically  malformed.  The  abdomen  is  distended  and  a  diastasis  of  the 
recti  muscles  is  observed.  A  double-jointedness,  resulting  from  a  muscular 


Fio.  67. — Mongoloid.     (Children's  Hospital,  Breslau,  Prof.  Tobler.) 

flaccidity  or  aplasia  is  common.  Finally  the  shortened  and  incurvated  small 
finger,  incident  to  hypoplasia  of  the  distal  phalange,  is  in  evidence. 

The  demeanor  of  the  imbecile  or  idiotic  child  is  very  characteristic. 
While  it  is,  at  first,  apathetic,  by  the  end  of  the  second  year,  or  even  later, 
it  becomes  restless,  active  and  aggressive,  with  a  tendency  to  imitation,  to 
make  grimaces,  and  to  gesticulate  in  an  ape-like  fashion.  It  employs  itself 
energetically  with  all  sorts  of  mischief,  in  the  way  of  tipping  over  objects, 
pulling  things  apart,  and  especially  in  climbing.  It  likes  to  talk,  but  fool- 
ishly; it  gives  the  more  or  less  definite  impression  of  a  happy  and  lively  dis- 
position, adaptive  to  its  surroundings. 

This  mental  change,  which  is  hailed  with  joy  by  the  layman,  as  evidence 
of  decided  progress  in  the  psychic  development  of  the  child  hardly  ever  leads 
to  the  attainment  of  useful  coordinated  acts  and  purposeful  mental  capac- 
ity. The  Mongolian  child  hardly  ever  learns  to  speak  correctly,  to  com- 


240 


TEXT-BOOK  OF  PEDIATRICS 


prehend  any  great  number  of  words,  to  recognize  its  surroundings,  to  keep 
itself  clean  and  the  like.  It  is  scarcely  ever  capable  of  school  training  but 
remains  upon  its  mentally  low  plane  or  falls  back  into  a  mental  torpor.  Its 


FIG    68. — Twenty-one-month-old  child  with  mongoloid  idiocy.    Brachycephaly, 
typical  form  of  face  and  attitude,  strabismus. 

special  love  of  music  is  often  noticeable.    Milder  cases  generally  acquire  ab- 
normal habits. 

The  skeleton  is  affected  by  a  group  of  facultative  qualities,  such  as 
retarded  growth,  delayed  development  of  the  epiphysial  centres  of  ossifica- 
tion, delayed  dentition,  tardy  closure  of  the  fontanelles.  Chicken-breast  is 
of  common  occurrence.  In  the  reproductive  system  there  is  a  lack  of  de- 
velopment- of  the  sexual  characteristics 
and  functions.  Mongolism  in  its  later 
course  is  not  infrequently  found  in  asso- 
ciation with  true  hypothyreosis,  with  its 
characteristic  physiogonomy,  myxedema, 
microglqssia,  faulty  breathing  and  sub- 
normal temperatures.  It  is  also  compli- 
cated, sometimes,  with  rickets  or  with 
adenoid  vegetations  and  their  sequela. 
The  general  defect  may  be  coincident, 
too,  with  a  number  of  congenital  mal- 
formities,  e.  g.,  heart  lesions,  cleft  palate, 
polydactylia,  etc. 

Atypical  cerebral  convolutions  sug- 
gest a  more  or  less  constant  structural 
substratum  of  the  psychic  syndrome 
of  mongolism. 

The  skeletal  symptoms  are  based 
upon  fatty  and  interstitial  changes  in 
the  bone-marrow,  with  the  formation  of 
transverse  bands  of  bone  at  the  epi- 
physeo-diaphyseal  junction.  This  anatomic  basis  of  the  hypothyreosis 
and  of  such  sexual  symptoms  as  the  delay  in  the  development  of  the  repro- 
ductive glands  is  to  be  found  in  a  hypoplasia  of  the  thyroid  gland  with  pro- 
liferation of  its  interstitial  tissue. 

The  semigenesis  of  the  mongoloid  habitus  itself  is  still  rather  obscure. 
It  may  be  readily  imagined  that  an  unknown  constitutional  injury  affecting 


FIG.  69. — Eighteen-month-old  girl  with 
indistinct  but  recognizably  mongoloid  fea- 
tures. Later  developed  into  a  typical  mon- 
goloid idiot. 


PATHOLOGY  OF  GLANDS  OF  INTERNAL  SECRETION  241 

the  cerebral  cortex  may  also  affect  the  bone-marrow  and  the  several  glands 
of  internal  secretion,  either  directly  or  indirectly,  without  producing  any 
characteristic  or  constant  structural  change. 

The  first  somatic  indication  of  mongoloid  degeneracy,  in  the  physiog- 
nomonic  appearance,  may  probably  be  noticeable  at,  or  soon  after  birth.  The 
psychic  manifestations  attract  attention  during  the  first  year.  The  laity 
and  physicians  who  have  not  learned  to  recognize  Mongolism  often  miss  any 
clear  picture  of  the  disease.  This  is  surprising  enough  to  the  man  of  experi- 
ence. But  very  rarely  does  a  general  disappearance  of  all  symptoms  and  a 
more  or  less  complete  recovery  from  the  disease  occur  in  the  course  of  the 
child 's  development.  The  morbidity  and  the  mortality  of  the  Mongoloid 
type  is  surely  very  great. 

Therapy. — Hypothyreosis,  coincident  with  Mongolism,  can  be  overcome 
with  thyroid  treatment.  But,  in  spite  of  the  fact  of  its  popularity  among 
mothers,  this  treatment  has  no  distinct  affect  upon  the  Mongolism  itself. 
It  may  be  readily  understood  that  any  stimulation  of  the  metabolic  func- 
tions by  the  active  principles  of  the  thyroid  gland  may  have  a  favorable, 
but  non-specific  influence  upon  the  somatic  and  psychic  processes,  particu- 
larly in  the  apathetic  stage.  This  effect,  however,  never  suffices  to  make 
the  patient  anything  but  refractory  to  pedagogic  training.  He  remains 
therefore,  socially  impossible.  Furthermore,  the  thyroid  treatment  has  its 
elements  of  danger  (heart  failure,  nephritis,  stomatitis,  etc). 


m. 

DISEASES  OF  THE  DIGESTIVE  SYSTEM 

BY 

H.  FINKELSTEIN  and  L.  F.  MEYER, 

Berlin. 

REVISED  AND  EDITED  BY 

Dr.  JOSEPH  BRENNEMANN, 

Attending  Pediatrician,  Children's  Memorial  Hospital,  Chicago,  111. 

DISEASES  OF  THE  MOUTH 

STOMATITIS 

INJURIES  of  many  kinds,  thermal,  chemical  and  bacterial,  may  cause  a 
primary  inflammation  of  the  mucous  membrane  of  the  mouth.  They  may 
also  become  secondarily  involved  when,  in  the  course  of  general  diseases, 
a  weakening  of  the  local  and  general  resistance  causes  a  predisposition  to  the 
growth  of  pathogenic  organisms,  as,  for  instance,  in  all  kinds  of  fever, 
gastro-intestinal  disturbances,  etc.  Finally,  changes  of  the  mucous  mem- 
brane may  be  symptoms  of  many  general  infections  (measles,  scarlet 
fever,  etc.). 

Catarrhal  stomatitis  is  the  most  common  and  important  of  the  primary 
forms.  A  diffuse,  dark,  reddening  appears  upon  the  swollen,  readily  bleed- 
ing, mucous  membrane  of  the  gums,  cheeks  and  fissured  lips,  while  the 
tongue,  usually  covered  with  a  heavy  white  coat,  appears  roughened 
because  of  the  swelling  of  its  papillae.  In  children  with  teeth,  we  may  have 
salivation  which  irritates  the  skin  surrounding  the  mouth;  fetor  exists,  and, 
in  severe  grades,  restlessness.  The  feeding  is  interfered  with  because  of 
pain.  Slight  rises  of  temperature  and,  occasionally,  slight  regional  adenitis 
occur.  In  new-born  and  very  young  children  catarrhal  stomatitis  presents 
several  peculiarities.  It  is  usually  accompanied  by  thrush  and  Bednar's 
aphthae,  traumatic  palatal  ulcers,  pterygoid  ulcers,  (Fig.  70),  i.  e.,  gray 
exudations  on  the  mucous  membrane  of  the  palate  which  may  change  into 
superficial  eroded  sores  which  are  typical  in  their  location  upon  both  sides 
on  the  pterygoid  procese  and  on  the  median  raphe.  On  the  process,  they 
are  usually  round  and  on  the  raphe  elongated.  Of  the  various  attempts  at 
explanation  of  these  ulcerations,  but  one  is  correct;  they  are  nothing  more 
than  mechanical  erosions  caused  by  attempts  at  cleansing  the  mouth. 
Bednar's  aphthae  always  point  to  ignorance  in  the  treatment  of  mouth 
conditions.  At  the  time  of  the  first  dentition  a  special  predisposition  to 
catarrhal  conditions  of  the  mouth  exists.  The  so-called  "epithelial  pearls," 
yellowish  white  masses,  the  size  of  a  pinhead,  are  frequently  seen  on  the 
median  line  of  the  hard  palate.  They  are  supposed  to  be  inclusions  of  nests 
of  epithelium  formed  by  the  closure  of  the  structure. 
242 


243 


The  prognosis  of  the  disease  is  good.  With  proper  treatment  and  care  of 
the  all-important  general  disease,  healing  may  be  expected  in  a  few  days.  On 
the  other  hand,  there  is  the  possibility  of  complications,  especially  of  a 
septic  nature. 

The  most  important  and  successful  prophylactic  measure  in  infants  is 
the  omission  of  the  customary  mouth  cleansing.    Epstein  has  shown  that 
washing  the  mouth  causes  traumatic  aphthae  and  that  the  omission  of  this 
routine  scrubbing  avoids  catarrhal  conditions.    So  long  as  a  child  is  not 
given  anything  to  chew  and  nothing  becomes  lodged  between  the  teeth  to 
decompose,  the  mouth  should  be  left  severely  alone.    This  is  also  the  best 
therapeutic  measure  in  successful  treatment.     With  older  children,  the 
condition  of  the  teeth  must  be  looked 
after.     Under  certain  circumstances, 
measures  used  for  the  aphthous  forms 
of  stomatitis  apply  to  this  type. 

Septic  Stomatitis. — Veryfrequently 
in  infants,  less  frequently  in  older 
children,  we  find  septic  catarrhal  con- 
ditions of  the  mouth.  These  are 
characterized  by  severe  purulent  in- 
flammation and  often  by  circum- 
scribed or  flattened  fibrinous  plaques 
with  a  tendency  to  ulcer  formation. 
Accompanying  these  severe  general 
symptoms,  high  fever  and,  not  uncom- 
monly, the  picture  of  general  septic 
poisoning  appears.  Locally,  spreading 
necroses  and  gangrenous  disintegra- 
tion are  occasionally  seen.  In  other 
cases,  the  dental  germs  may  become 
inflamed  and  form  abscesses.  Com- 
plications, in  the  way  of  lymphaden- 
itis, inflammation  of  the  salivary 
glands,  phlegmon,  erysipelas  and 
septic  metastases,  are  not  uncommon. 

An  especially  appalling  condition  is  seen  in  the  pseudodiphtheria  of  the 
new-born  (Epstein).  In  feeble  children  during  the  first  few  weeks  of  life, 
and  usually  arising  from  aphthae,  tough,  flat,  necrosing  deposits,  following 
confluent  fibrinous  exudates,  appear  which  frequently  attack  the  underlying 
soft  parts  and  bones.  They  spread  rapidly  to  the  pharynx,  nose,  larynx  and 
esophagus.  At  autopsy,  this  disease  may  be  mistaken  for  lesions  caused  by 
the  ingestion  of  caustics. 

The  cause  of  septic  stomatitis  is  to  be  found  in  virulent  pyogenic  organ- 
isms, most  commonly  streptococci.  Diphtheria  may,  at  times,  be  the  cause. 
The  lowering  of  resistance  due  to  an  existing  or  intercurrent  disturbance  of 
nutrition  may  be  the  fundamental  cause  and  gives  an  especially  bad  prog- 
nosis. The  necrosed  and  gangrenous  forms  are  doubtless  found  only  in 


FIG.  70. — Catarrhal  stomatitis,  thrush  and 
Bednar's  aphthae  in  an  infant.  (Berlin  Chil- 
dren's Asylum.) 


244  TEXT-BOOK  OF  PEDIATRICS 

generally  run  down  children.  A  suitable  feeding  therapy  often  gives  the 
first  and  most  surprising  results,  when  all  other  measures  have  had  only  a 
palliative  effect. 

Aphthous  stomatitis  (canker  sore  mouth),  is  characterized  by  the  appear- 
ance of  white  or  yellowish,  round,  lenticular  plaques  slightly  raised  upon  an 
hyperemic  base,  found  especially  on  the  anterior  portion  of  the  mouth  and 
tongue,  while  the  posterior  portions,  the  soft  palate  and  the  tonsils  are  much 
less  frequently  attacked.  These  "aphthse"  may  become  confluent  here  and 
there  and  form  large  patches  or  areas.  They  are  the  result  of  the  effusion 
of  a  fibrinous  exudate  into  the  upper  layers  of  the  epithelium. 

The  eruption  occurs  with  local  symptoms,  pain,  consequent  difficulty 
of  feeding,  salivation,  fetor,  and  fever.  The  duration  of  the  disease  is  usu- 
ally from  one  to  two  weeks.  In  most  cases  recovery  then  takes  place.  With 
feeble  children,  however,  a  disturbance  of  nutrition  or  a  pneumonia  may  be 
added  to  this,  or  a  severe  local  disease  of  long  duration  may  be  ushered  in 
by  the  aphthse.  With  high  and  continuous  fever,  disseminated  membran- 
ous exudations,  ulcerations,  extreme  swelling  and  fissuring  of  the  lips  and 
irritation  of  the  surrounding  skin  may  occur.  Septic  complications  are  not 
uncommon.  These  are  probably  the  result  of  a  septic  stomatitis  implanted 
upon  the  soil  of  the  aphthse.  In  the  diagnosis,  one  must  consider  true 
diphtheria;  and,  aside  from  the  bacterial  examination,  the  appearance  of 
typical  lentil  shaped  plaques  is  diagnostic. 

Herpetic  stomatitis,  which  is  not  uncommon  in  children,  gives  a  similar 
exudation  when  the  small  vesicles  have  broken.  The  mode  of  onset,  the 
group  formation  of  the  efflorescence  and  the  absence  of  infective  organisms 
make  the  differentiation  possible.  The  cause  is  unknown.  Some  observers 
connect  the  disorder  with  the  foot  and  mouth  disease  of  cattle.  It  is  un- 
doubtedly transmissible  and  the  companions  of  the  child  should  be  pro- 
tected against  infection  by  special  measures  (isolation,  separate  utensils, 
etc.).  In  the  treatment,  energetic  local  measures  should  be  avoided.  Rins- 
ing or  irrigating  with  warm  infusions  or  with  antiseptic  solutions,  as  potas- 
sium permanganate,  hydrogen  peroxide,  or  boric  acid  solution  may  be 
employed.  With  tractable  children,  the  disease  spots  may  be  touched  with 
a  2  per  cent,  solution  of  silver  nitrate  or  phenol.  For  the  pain,  penciling 
before  eating  with  anesthetizing  solutions  (novocaine,  1  per  cent,  or  3  per 
cent,  eucain  lactate)  or  dusting  with  sterilized  bolus  alba,  to  which  one  of  the 
above  anesthetics  has  been  added,  is  useful.  The  anesthesin  candies  may 
also  give  relief  at  times.  The  nourishment  must  be  liquid;  highly  seasoned 
soups  are  to  be  avoided  because  of  the  pain  they  cause. 

Ulcerative  Stomatitis. — Ulcerative  inflammation  of  the  buccal  mucous 
membrane  is  found  only  when  teeth  are  present  and  most  commonly  in 
children  after  the  sixth  year.  It  begins  as  a  purulent  gingivitis  at  a  molar 
tooth,  recognizable  by  a  yellow  line,  and  soon  identifies  itself  by  a  discolored 
necrotic  sloughing.  By  the  destruction  of  the  gums,  the  roots  of  the  teeth 
are  bared  and  the  teeth  themselves  loosened.  In  milder  forms  the  inflam- 
mation does  not  spread ;  in  the  more  severe,  it  may  cover  the  whole  alveolus 
and  be  carried  to  neighboring  parts  of  the  mouth  and  tongue,  and  at  times 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


245 


even  to  the  palate  (see  ulcerative  angina).  The  intense  fetor  is  character- 
istic. External  adjoining  tissues,  as  well  as  the  regional  lymph  nodes,  be- 
come swollen.  Fever  and  other  general  symptoms  usually  occur  with  these 
lesions  and  with  the  pain  and  the  far-reaching  influence  upon  feeding,  a 
severe  disease-picture  is  produced. 

In  spite  of  this,  the  prognosis  is  usually  not  bad.  Normally,  the  process 
ends  in  one  to  two  weeks  and  scar  formation  begins.  But  in  weak  children, 
deep  necroses,  similar  to  noma,  and  local  and  general  septic  comph' cations 
may  set  in  and  cause  death. 

The  occurrence  of  ulcerative  stomatitis  only  when  teeth  are  present  and 
especially  when  these  are  uncared  for  or  carious,  gives  direct  indication  of 
the  cause.  In  fact,  we  find  in  smears  from  the  ulcers,  fusiform  bacilli  and 


Fia.  71. — Fusiform  bacilli  and  spirilla  in  ulcerative  stomatitis.    (Berlin  Orphan  Asylum.) 

spirochsetes  (Fig.  71)  associated,  as  they  are  in  carious  teeth,  and 
their  etiologic  significance  can  hardly  be  doubted.  Of  course,  they  may  not 
be  looked  upon  as  primary  disease  producers,  and  that  their  pathogenicity 
demands  a  previous  lowering  of  the  general  health  is  shown  by  the  fact 
that  ulcerative  stomatitis  occurs  most  frequently  in  cachectic  children  or 
those  weakened  by  other  infections.  The  microscopic  identification  of  the 
bacteria  is  important  for  diagnosis.  For  differentiation,  mercurial  stomati- 
tis and  scorbutic  stomatitis  must  be  considered. 

The  treatment  is  that  of  all  stomatites.  The  feeding,  especially,  is  of 
extreme  importance.  For  local  treatment,  cauterization,  once  or  twice 
daily,  with  a  5  per  cent,  solution  of  chloride  of  zinc,  or  penciling  with  tinc- 
ture of  iodine  or  with  95  per  cent,  phenol  by  glass  rod,  is  recommended. 
Dusting  with  antiseptic  powders,  xeroform,  iodoform,  bismuth-iodo- 
gallate,  in  small  quantities  to  prevent  poisoning,  is  also  useful.  Ulce rations 
in  the  recesses  of  the  mouth  are  favorably  influenced  by  applications  of 


246  TEXT- BOOK  OF  PEDIATRICS 

iodoform  gauze  saturated  in  a  solution  of  aluminum  acetate.  Recently 
intravenous  injections  of  salvarsan  and  local  applications  of  a  10  per  cent, 
solution  of  the  same  in  water,  glycerin  or  oil,  have  been  used  in  adults  with 
surprising  success  and  this  treatment  should  also  receive  consideration  in 
extreme  cases  in  children. 

Hemorrhagic  stomatitis  in  infancy  and  early  childhood  is  usually  a 
symptom  of  scurvy.  Other  infectious  hemorrhagic  stomatites,  also  of  a 
serious  nature,  occur  but  rarely  at  this  age. 

In  older  children  we  occasionally  see  a  condition  resembling  scurvy, 
without  its  usual  history,  which  may  end  in  death  by  uncontrollable 
bleeding. 

Noma. — Gangrenous  stomatitis,  also  called  noma  or  water  cancer, 
occurs,  with  few  exceptions,  only  in  children  who  are  initially  feeble  and 
have  been  affected  by  other  diseases  (chiefly  measles,  typhoid,  diphtheria, 
disturbances  of  nutrition,  etc.).  It  usually  begins  opposite  one  of  the  pre- 
molars  with  a  small  discolored  infiltration  on  the  mucous  membrane  of  the 
cheek,  which  soon  pierces  the  cheek  and  is  then  seen  externally  as  a  small 
brownish  spot.  This  Spot  rapidly  takes  on  the  black  color  of  necrotic  tissue ; 
it  enlarges  and  while  the  central  portion  disintegrates,  the  peripheral  lines 
spread  with  startling  rapidity,  so  that  a  large  part  of  the  cheek  or  even  the 
whole  side  of  the  face  may  be  affected  in  a  few  days.  After  the  sloughing  of 
the  foul,  putrid  mass  the  interior  of  the  mouth  is  exposed.  The  process  is 
not  terminal  and  continues  to  necrosis  of  the  bones.  At  the  borders,  toward 
the  normal  tissue,  we  find  edematous  swelling  with  little  or  no  inflammatory 
reaction.  The  general  well-being  is  soon  affected;  fever,  cachexia,  and  diar- 
rhoea consume  the  strength  of  the  patient  and  usually  cause  death.  Most 
cases  last  but  a  short  time ;  only  a  few  extend  over  several  weeks.  Spontane- 
ous healing  does  occur,  but  very  rarely.  Scar  formation  in  the  lesions 
naturally  takes  a  long  time. 

In  the  etiology  of  noma,  cachectic  conditions  are  of  the  same  importance 
as  in  ulcerative  stomatitis.  The  agent  which  acts  with  such  fatality  upon 
susceptible  soil  is  not  yet  definitely  known.  In  many  cases,  a  massed 
grouping  of  a  cladothrix-like  micro-organism,  growing,  in  threads  at  the 
border  between  the  diseased  and  normal  tissue,  has  been  found  and  there 
are  many  indications  that  this  may  be  of  etiologic  importance.  An  occa- 
sional case,  perhaps  may  be  caused  by  diphtheria. 

Treatment. — But  little  is  to  be  expected  from  internal  medication.  The 
antiseptics  (H2O2),  as  well  as  the  caustics  (40  per  cent,  chloride  of  zinc  paste), 
are  useless ;  nor  is  the  actual  cautery  any  better.  The  best  results  have  been 
reported  from  energetic  surgical  interference,  the  excision  of  all  diseased 
tissue,  bony  structures  as  well  as  soft  parts,  followed  by  the  cautery. 
Plastic  operations  are  necessary  after  healing. 

Thrush. — Thrush  is  peculiar  to  infancy.  In  older  children  it  occurs 
rarely  and  only  accompanies  extreme  cachexia,  as  in  adults.  In  the  infant, 
however,  it  may  occur  upon  very  slight  disturbance,  the  severe  forms  only 
appearing  with  more  marked  cachexia. 

The  disease  appears  first  in  the  form  of  pinhead,  or  larger,  white,  and 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  247 

slightly  raised  patches  (see  Fig.  70),  which  later  become  confluent  into  thick 
flat  deposits  which  may  occupy  the  whole  mouth  and  take  on  a  yellowish 
or  reddish  discolorization  from  blood-stain.  They  are  quite  adherent  and 
consist,  as  is  shown  by  smears  under  the  microscope,  of  thread-like  mycelia 
and  round  shining  gonidii  of  a  fungus  which,  according  to  Plaut,  is  closely 
related  to  the  monilia  Candida,  which  anchors  itself  by  the  growth  of  its 
mycelia  between  the  epithelial  cells. 

It  was  formerly  supposed  that  thrush  demanded  severe  general  disease 
for  its  development.  Today,  however,  it  is  known  that  it  is  due  to  a  com- 
paratively harmless  nosoparasite  and  that  diarrhoeas  and  other  severe  or 
fatal  general  diseases,  in  connection  with  which  it  is  found,  are  not  its  results, 
but  rather  create  a  predisposition  which  permits  its  growth  as  an  intercur- 
rent  malady.  However,  even  children  with  such  diseases  may  remain 
almost  or  entirely  free  from  thrush,  so  long  as  the  abuse  of  mouth-washing 
does  not  produce  lesions  of  the  buccal  epithelium  and  a  traumatic  stoma- 
titis which  appears  to  be  absolutely  necessary  for  the  growth  of  the  fungus. 
The  consensus  of  experience  of  all  institutional  physicians  has  taught  us 
that  with  the  prohibition  of  mouth-washing,  thrush,  which  formerly  could 
not  be  exterminated,  disappears  from  the  wards. 

Thrush  itself  is  not  dangerous.  With  a  very  rare  involvement  of  the 
larynx,  however,  a  stenosis  may  occur,  or  when  the  pharynx  is  affected  there 
may  be  difficulty  in  swallowing.  There  is  reason  to  believe  that  the  fungus 
may  get  into  the  general  circulation,  causing  embolic  abscesses  or  even 
severe  general  disturbances  (Heubner). 

The  most  certain  prophylactic  against  thrush  is  the  omission  of  mouth- 
cleansing;  and,  added  to  this,  the  increase  of  the  resistance  of  the  child  by 
proper  nutrition.  The  normal  mucous  membrane  of  the  mouth  is  not  a 
favorable  soil  for  the  fungus.  Thrush  will  heal  if  the  mouth  is  left  alone  and 
the  general  health  is  improved.  All  penciling  or  rubbing  hinders  healing, 
or  at  least  delays  it.  An  aid  to  healing  may  be  secured  from  the  sucking  of 
pacifiers  consisting  of  gauze-covered  cotton  tampons  saturated  or  powdered 
with  fungus  killing  substances  [boric  acid  powder  and  benzosulphinide 
(saccharin)  or  20  per  cent,  boroglyceride]. 

ANOMALIES  OF  THE  TEETH  AND  TEETHING 

The  presence  of  teeth  at  birth  is  not  uncommon.  Frequently  the  central 
incisors  are  present,  although  the  bicuspids  or  canines  have  also  been 
observed.  They  are  probably  caused  by  a  misplacement  of  the  dental  germ 
and  in  this  event  are  without  roots  and  being  loose  in  the  gum  should  be 
removed.  Or  they  may  be  developed  from  the  alveolus  as  a  result  of  an 
eaily  germ  centre  or  an  accelerated  growth.  In  the  latter  variety,  inflam- 
mation of  the  peridental  membrane  is  frequent.  This  may  cause  necrosis 
of  the  alveolus  if  the  tooth  is  not  extracted. 

Early  appearance  of  the  teeth  is  noted  occasionally  as  a  family  peculi- 
arity. It  may  occur  in  connection  with  general  and  sexual  precocity.  The 
chief  cause  of  retarded  and  irregular  dentition  is  rickets.  Of  course,  other 


248  TEXT-BOOK  OF  PEDIATRICS 

facts  (severe  disturbance  of  nutrition,  myxedema,  mongolism,  etc.)  may 
enter  into  its  causation. 

In  most  cases,  dentition  occurs  without  symptoms.  The  old  doctrine  of 
difficult  dentition,  which  taught  that  fever,  convulsions,  mental  symptoms, 
cough,  dysenteries,  eczemas  and  the  like  may  be  caused  by  the  appearance 
of  the  teeth,  is  today  accepted,  if  at  all,  in  but  a  very  limited  and  circum- 
scribed sense.  Restlessness,  disturbance  of  sleep,  local  pruritus,  slight  stoma- 
titis may  possibly  be  caused  by  dentition.  It  is  possible  that  variations  of 
temperature  and  crops  of  "tooth  rash"  may  be  directly  connected  with  it, 
especially  in  neurotic  children.  This  also  applies  to  the  occurrence  of 
convulsions,  which  must  be  considered  as  manifestations  of  spasmophilia. 
All  other  "teething  symptoms"  are  more  than  questionable.  According 
to  Heubner,  the  phenomena  of  growth  in  the  jaw  during  dentition  are 
of  sufficient  importance  to  cause  a  higher  demand  upon  the  total  energy 
of  the  body  and  may  thus  make  the  child  more  prone  to  exhibitions 
of  spasmophilia. 

Disturbances  of  the  dental  follicles  also  occur  with  the  development  of 
the  permanent  teeth  and  appear  in  early  years  in  the  form  of  erosions, 
cracks,  notching,  softening  and  tendency  to  early  caries.  Rickets  plays  a 
major  part  in  their  causation  as,  also,  does  congenital  syphilis  which  pro- 
duces the  so-called  Hutchinson's  teeth.  A  circular  green  deposit  at  the 
base  of  the  temporary  teeth  or,  more  commonly,  circular  caries  is  especially 
frequent,  but  not  pathognomonic,  in  scrofulo-tuberculous  children  (H. 
Neuman).  It  justifies,  to  a  certain  extent,  a  suspicion  of  this  condition. 
The  temporary  dentition  should  receive  the  same  care  as  the  permanent  set. 
Brushing  with  a  soft  brush  with  a  non-gritty  dentifrice  is  an  easily  acquired 
habit.  The  early  loss  of  teeth  from  the  jaw  delays  its  proper  growth  and 
also  affects  the  permanent  teeth.  Anomalies  of  position  favor  the  occur- 
rence of  caries  and  its  complications  and  early  orthodontia  is  advisable. 

DISEASES  OF  THE  SALIVARY  GLANDS 

Of  the  acute  diseases  of  the  salivary  glands  (chiefly  the  parotid)  other 
than  mumps,  it  is  necessary  to  discuss  only  those  that  are  secondary  to 
purulent  inflammations  of  the  mouth.  The  most  frequent  of  chronic  con- 
ditions is  ranula,  the  congenital  or  acquired  retention  cysfof  the  sublingual 
gland.  As  rarities,  many  others  may  be  mentioned,  especially  in  the  pa- 
rotid; new  growths,  swellings  of  intermittent  character,  ptyalolithiasis, 
tuberculosis  and  a  chronic  inflammation  belonging  to  the  symptom-com- 
plex of  Mikulicz. 

DISEASES  OF  THE  TONSILS,  THE  PHARYNX  AND 
THE  ESOPHAGUS 

ANGINA 

Angina  is  the  name  generally  applied  to  inflammatory  diseases  of  the 
pharynx  and  nasopharynx  which  occur  in  the  child,  as  well  as  in  the 
adult,  with  extreme  swelling  of  the  adenoid  tissue  involving  the  "lymphatic 
ring"  (Waldeyer),  which  surrounds  the  fauces  and  the  nasopharynx, 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  249 

resulting  in  the  hypertrophy  of  the  tonsils  and  adenoids  to  tumor-like 
masses.  This  region  is  usually  involved  in  its  entirety;  so  that  the  custom- 
ary differentiation  of  palatal  angina  (tonsillitis)  from  retronasal  angina 
is  not  always  justified,  even  though  the  different  parts  are  affected  in  vary- 
ing degree.  In  the  first  year  of  life,  the  affection  of  the  faucial  tonsil  is  much 
less  frequently  encountered  than  in  later  years,  while  the  retronasal  form  is 
more  common. 

CATARRHAL  ANGINA  AND  EXUDATIVE  ANGINA 

The  cause  of  angina?,  if  we  except  those  which  are  symptoms  of  general 
infectious  diseases  (scarlet  fever,  influenza,  cerebrospinal  meningitis,  etc.), 
are  the  usual  pyogenic  organisms  (such  as  streptococci,  pneumococci, 
micrococcus-catarrhalis,  etc).  In  many  cases  it  is  an  auto-infection  in 
which  an  accidental  cause  (exposure  to  cold,  vocal  strain,  or  other  diseases), 
lowers  the  resistance  of  the  body  and  gives  the  pathogenic  organisms 
inhabiting  the  mouth  opportunity  to  grow.  On  the  other  hand,  the  disease 
may  be  earned  from  person  to  person,  so  that  true  epidemics  occur.  Occa- 
sionally, the  possibility  of  scarlatina  sine  eruptione  must  be  considered. 
Aside  from  this,  an  individual  predisposition  seems  to  exist  because  of 
which  some  children  are  especially  prone  to  angina?.  More  important  even 
than  predisposition  in  the  local  sense  (hypertrophy,  the  tonsillar  crypts 
acting  as  reservoirs  of  infective  material),  is  the  general  predisposition, 
dependent  upon  lessened  immunity,  which  is  probably  connected  with 
lymphatic  conditions. 

The  general  symptoms  are  those  of  an  infection;  acute  onset,  with  chills, 
fever,  headache,  malaise,  convulsions  in  the  spasmophilic  and,  frequently, 
initial  vomiting  and  diarrhoea.  Older  children,  usually  but  not  invariably, 
complain  of  pain  in  swallowing.  The  submaxillary  and  cervical  glands  swell 
and  become  painful.  A  foul  breath  is  noticeable  and,  with  severe  grades 
of  swelling,  muffled  speech  and  probably  stridor.  Upon  inspection,  the  cause 
of  these  symptoms  is  found  to  be  one  of  the  various  forms  of  angina. 

Catarrhal  angina  is  an  inflammation  characterized  by  hyperemia,  mu- 
cous secretion  and  enlargement  of  the  lymph  nodes.  The  epithelium  has  a 
lack-lustre  appearance;  small  hemorrhages  occur,  but  no  membrane 
appears.  This  form  includes  the  larger  number  of  mild  attacks,  but  may  be 
accompanied  by  severe  symptoms.  Its  duration  is  usually  only  from  two  to 
three  days,  but  it  may  last  longer. 

Follicular  angina  is  to  be  differentiated  from  the  catarrhal  form  by  a 
marked  swelling  of  the  lymph  follicles  of  the  tonsils  which  show  gray  and, 
later,  yellowish,  round,  flat  or  raised  lesions.  These  are  equally  distributed 
over  the  tonsil  and  may  drop  out  or  cause  superficial  ulcerations. 

Lacunar  angina  differs  from  the  above  form  in  the  appearance  of  a  gray 
or  grayish-yellow  mucopurulent  exudate  which,  at  first,  may  cover  the 
whole  tonsil,  but  later  is  rubbed  off  from  the  exposed  parts  so  that  the 
exudate  is  found  in  the  crypts  only,  and  therefore  gives  a  lacunar  appear- 
ance. The  general  and  local  symptoms  are  usually  more  severe  than  in  the 


250  TEXT-BOOK  OF  PEDIATRICS 

former  types.  When  there  is  a  recurrence,  or  the  spread  of  infection  from 
one  side  to  the  other,  the  disease  may  be  of  long  duration. 

Circumscribed,  multiple,  fibrinous  exudations  upon  the  tonsils,  the 
palate,  etc.,  are  not  uncommon  in  grippal  angina.  Widespread  infiltration 
may  occur  in  septic  forms. 

The  inflammation  of  the  pharyngeal  tonsil  (retronasal  angina,  adenoid- 
itis,  pharyngeal  angina,  pharyngitis  superior)  is  of  great  importance.  The 
severe  interference  with  nasal  breathing,  the  rather  nasal  than  palatal 
voice  sounds,  the  involvement  of  the  ear  (sharp  lancinating  pains,  slight 
deafness),  the  purulent  discharge  from  the  nose,  are  diagnostic  of  this  con- 
dition. Upon  inspection,  the  nasopharynx  may  be  seen  to  be  covered  with 
mucous  and  pus.  Digital  or  rhinoscopic  examination  shows  the  tonsil 
inflamed  and  greatly  enlarged.  The  cervical  glands  are  swollen.  The 
course  and  duration  resemble  that  of  lacunar  angina,  but  in  this  condition 
long  continued  fever  is  common. 

Variations  of  the  usual  course  are  frequent.  In  some  cases,  excessive 
gastro-intestinal  symptoms  may  simulate  typhoid,  and  in  patients  of 
excessive  nervous  irritability  meningismus  may  arise.  In  retronasal  an- 
gina especially,  we  have  fever  of  long  duration  and  at  times  with  very 
slight  local  manifestations.  Fevers  of  one,  two  or  more  weeks  duration,  of  a 
remittent  or  intermittent  type,  which  lead  one  to  suspect  the  presence  of 
pus,  but  usually  end  benignly,  are  also  of  importance.  Further,  we  may 
have  chronic  recurring  angina3,  the  attacks  of  which  follow  one  another  so 
closely  as  to  cause  serious  disturbance. 

The  number  of  complications  is  very  large  indeed;  tonsillar  abscess, 
otitis  media,  exanthemata,  diseases  of  the  respiratory  organs,  lymphadenitis 
with  pus  formation,  in  particular,  and  others. 

Glandular  fever  (Filatow  and  E.  Pfeiffer)  is  the  term  applied  to  a  disease 
which  is  recognized  by  a  reddening  of  the  pharynx,  acute  swelling  of  the 
cervical  glands  and  frequently  by  involvement  of  other  lymph  node  groups, 
even  the  mediastinal  and  mesenteric,  and  which,  in  spite  of  severe  symp- 
toms, usually  goes  on  to  recovery,  without  abscess  formation,  after  a  dura- 
tion of  weeks.  In  this  disorder,  we  probably  have  to  deal,  not  with  an 
entirely  separate  disease  but  with  a  retronasal  angina  with  very  slight  local 
symptoms.  Glandular  fever  frequently  occurs  in  epidemics  and  probably 
stands  in  close  relation  to  la  grippe. 

When  we  consider  that  angina  represents  a  local  septic  infection,  it  may 
be  readily  understood  that  its  sequelae  present  many  conditions  which  appear 
as  symptoms  of  rheumatic  or  general  septic  infection.  To  this  class  belong 
erythema  nodosum  and  exudativum,  purpura,  nephritis  of  hemorrhagic 
type,  serous  and  purulent  inflammation  of  the  joints,  the  heart  and  body 
cavities,  osteomyelitis,  etc. 

The  diagnosis  of  angina  is  made  by  inspection.  This  should  be  done, 
even  when  no  subjective  symptoms  call  attention  to  the  throat.  The  con- 
sideration of  an  inflammation  of  the  regional  lymph  nodes  is  important. 
The  differentiation  from  scarlet  fever  may  cause  great  difficulty  in  cases 
with  erythematous  eruption.  In  these  instances,  the  indefinite  demarcation 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  251 

of  the  reddening  of  the  throat  and  the  absence  of  the  rasberry  tongue  is  of 
importance.  In  diphtheria  the  exudate  is  in  patches  and  is  not  lacunar, 
although  we  may  have  a  real  lacunar  angina  with  diphtheritic  cause, 
which  may  be  distinguished  by  bacteriologic  examination  or  by  the  sequelar 
paralysis  alone. 

Treatment. — Because  of  the  undeniable  infectiousness  of  many  anginse, 
isolation  is  advisable.  Treatment  consists  of  rest  in  bed,  careful  feeding, 
cold  applications  to  the  neck,  even  of  ice  packs ;  gargling  with  salt  water  and 
glycerin,  lemon  water,  weak  solutions  of  aluminum  acetate,  lime  water,  etc. 
Internal  remedies,  e.  g.,  potassium  chlorate  2  per  cent.,  1-2000  cyanate  of 
mercury,  are  better  avoided. 

Sweat-producing  measures  are  often  useful.  For  the  swollen  lymph 
nodes,  hot  applications,  causing  local  hyperemia,  give  good  results  both  in 
reducing  the  swelling  and  aiding  abscess  formation.  To  prevent  recur- 
rence, a  change  of  constitutional  conditions  should  be  brought  about  by 
diatetic  and  hygienic  prophylaxis. 

Membrano-ulcerative  Angina — (Vincent's  angina,  Plaut's  diphtheroid 
angina,  angina  a'  bacille  fusiform.)  In  membranous  angina,  we  find  tough, 
spreading  membranes  which  are  due  to  an  extension  of  the  necrotic  exudate. 
into  the  mucosa.  After  the  sloughing  of  these  necrotic  membranes,  distinctly 
circumbscribed  ulcers  of  varying  depths  are  seen.  The  entire  pharynx  is 
swollen  and  there  is  a  tendency  to  hemorrhage  from  the  mucous  membrane. 
A  strong  fetor,  resembling  that  of  ulcerative  stomatitis,  is  characteristic. 

Distinction  is  to  be  made  between  the  milder  diphtheroid  form,  with 
more  superficial  membrane  formation  and  smaller  ulcers,  and  the  membrano- 
ulcerative  form  with  deeper  and  more  widespread  lesions. 

In  many  cases,  the  fever  and  general  symptoms,  as  well  as  the  objective 
signs,  are  extremely  mild,  so  that  only  the  routine  examination  of  the  throat 
brings  out  the  cause  of  the  illness.  The  contrast  between  the  mild  gen- 
eral symptoms  and  the  severe  local  changes  is,  in  fact,  quite  characteristic 
of  the  disease,  although  cases  are  seen  with  high  fever  and  typical  angi- 
nal symptoms. 

The  course  of  the  diphtheroid  form  resembles  the  ordinary  anginse. 
Transitional  forms  exist.  In  these,  the  long  duration,  the  slowness  of  the 
sloughing  process  and  the  tendency  to  recurrence  are  quite  characteristic. 
The  disease  usually  ends  in  recovery;  only  exceptionally,  and  probably  in 
cachectic  children,  have  extended  necroses,  with  a  fatal  result,  been  reported. 
Complications  are  hardly  to  be  feared. 

The  same  fusiform  bacillus  and  spirochseta  that  cause  ulcerative  stoma- 
titis, may  be  assigned  as  probably  etiologic  factors.  A  certain  infectivity 
undoubtedly  exists  in  grouped  cases  observed  in  families,  houses  or  barracks; 
but  the  transmissibility  is  evidently  not  very  great. 

Together  with  the  throat  findings  and  the  characteristic  fetor,  the 
demonstration  of  the  fusiform  bacillus  and  spirochseta  in  a  smear  stained 
with  fuchsin,  is  diagnostic  (Fig.  71).  In  the  differential  diagnosis,  diph- 
theria and  syphilis  must  be  considered.  This  form  of  angina  often  resembles 
the  latter  disease  so  much  that  French  authors  have  applied  the  term 


252  TEXT-BOOK  OF  PEDIATRICS 

"  chancrif orm "  to  its  lesions.  The  absence  of  other  signs  of  syphilis,  the 
negative  results  of  cultures  for  diphtheria  bacilli  and,  finally,  its  course 
are  diagnostic. 

The  treatment  is  that  usual  for  anginse.  The  cleansing  of  the  ulcers  may 
be  attempted  by  touching  with  hydrogen  peroxide  and  by  the  application  of 
antiseptic  powders.  Of  late,  good  results  have  been  obtained,  as  in  ulcer- 
ative  stomatitis,  with  salvarsan. 

Rare  forms  of  gangrenous  angina,  of  unknown  origin  and  of  doubtful 
prognosis,  with  extremely  foul-smelling,  progressive  disintegration  of  the 
entire  throat  and  a  tendency  to  hemorrhage  are  seen.  The  very  fatal  serous 
or  seropurulent  pharyngeal  phlegmon  and  pharyngeal  erysipelas  may 
also  oc'jur  in  the  child. 

HYPERPLASIA  OF  THE  TONSIL 

Tonsillar  hyperplasia,  leading  to  a  globular  or  longitudinal  tumor, 
frequently  extending  far  downward  into  the  pharynx  or  developing  into  a 
ragged  polyp-like  growth,  is  closely  related  in  its  etiology  and  course  to 
adenoid  growths  (q.  v.).  Treatment  should  not  be  too  energetic.  It  is 
generally  well  to  await  a  gradual  physiologic  recession.  Tousillectomy  is  to 
be  advised  only  in  case  of  large  protruding  tumors.  The  hope  of  curing  a 
frequently  recurring  angina  by  snipping  off  the  tonsil  is  very  slight.  A 
harmless  diphtheroid  membrane  is  always  formed  upon  the  wound  after  the 
operation.  It  must  not  be  forgotten,  however,  that  true  diphtheria  may 
occur  there. 

Tumors  of  the  pharynx  are  usually  congenital  or  are  formed  upon  a 
congenital  base;  and  among  them  we  must  consider  dermoids,  lipomata, 
fibromata  and  fibrosarcomata  (so-called  nasopharyngeal  polypi).  The 
most  serious  is  the  lymphosarcoma  of  the  tonsil,  which  must  be  considered 
in  cases  of  rapidly  growing  unilateral  swelling  of  the  tonsil. 

RETROPHARYNGEAL    LYMPHADENITIS    AND    RETRO- 
PHARYNGEAL  ABSCESS 

The  lymph  channels  of  the  nasopharynx  pass,  in  part,  on  their  way  to 
the  cervical  nodes,  through  lateral  pharyngeal  groups  which  lie  at  the  level 
of  the  atlas  behind  the  tonsils.  These  in  turn  communicate  with  the  deep 
cervical  nodes.  They  may  also  be  connected  with  small,  inconstant  nodes 
which  become  obliterated  during  childhood  and  which  lie  in  the  median  line, 
at  the  level  of  the  odontoid  axis,  imbedded  in  the  fascia.  In  the  event  of 
inflammatory  conditions  in  the  territory  drained  by  these  glands,  they  may 
enlarge,  become  inflamed  and  finally  suppurate.  This  is  the  ca.use  of  the 
occurrence  of  retropharyngeal  lymphadenitis  or  retropharyngeal  abscess. 

The  primary  process  is  usually  a  coryza  or  a  retronasal  angina.  The 
condition  may  also  be  connected  with  lues,  measles,  or  scarlet  fever.  Fur- 
ther, wound  infection  from  rhagades  and  ulcers  must  be  considered. 
Idiopathic  lymphadenitis,  of  which  older  physicians  speak,  does  not  exist. 
Streptococci,  and  less  frequently  influenza  bacilli  or  other  micro-organisms 
are  etiologic  factors. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  253 

The  disease  occurs  especially  in  the  first  two  years  of  life.    Later  on  it  is " 
less  common,  probably  because  of  the  obliteration  of  the  nodes  involved. 
A  simple  swelling  of  the  lymph  nodes  is  quite  frequent ;  the  severer  forms, 
on  the  contrary,  are  comparatively  rare. 

The  first  stage  of  the  disease  causes  no  symptoms  aside  from  fever 
and  only  by  digital  examination  can  the  movable  swelling,  which  may  be  of 
the  size  of  a  bean  or  hazel-nut,  be  discovered.  More  severe  symptoms 
appear  when  the  swelling  becomes  larger  and  the  infiltration  of  the  sur- 
rounding connective  tissue  more  extensive.  Among  these  may  be  mentioned 
dysphagia,  rattling  and  gurgling  in  the  throat  due  to  the  collection  of  mucus 
above  the  obstruction,  a  muffled  voice,  and  pharyngeal  stridor.  The  rigid 
pose  of  the  head,  at  tunes  resembling  torticollis,  taken  to  guard  the  painful 
swelling  from  pressure,  is  notable.  The  superficial  glands  are  frequently 
involved.  The  condition  may  cause  attacks  of  suffocation  or,  extending  far 
down,  may  produce  edema  of  the  larynx.  The  swelling  of  the  throat  may  then 
be  noted  upon  inspection;  but  better  information  is  given  by  palpation, 
which  shows  whether  there  is  still  a  hard  infiltration  or  a  fluctuating  abscess. 

Course. — Many  simple  swellings  and  tissue  infiltrations  recover  spon- 
taneously; only  a  few  go  on  to  abscess  formation.  In  the  latter  cases, 
recovery  may  set  in  after  evacuation.  Frequently,  the  neighboring  nodes 
are  affected  and,  becoming  suppurative  and  confluent  with  the  retropharyn- 
geal  group,  form  a  large  abscess.  Extension  into  the  mediastina  and  later, 
pyemia  may  occur.  Spontaneous  rupture  may  cause  death  by  inspiration 
of  the  pus. 

With  early  recognition  and  treatment  the  prognosis  is  favorable. 

The  diagnosis,  frequently  missed  by  beginners,  is  made  upon  the  signs 
of  stenosis  and  the  discovery  of  swelling  by  palpation.  Differentiation  from 
laryngeal  diphtheria,  without  recourse  to  digital  examination,  should  be 
possible  by  the  pharyngeal  tone  of  the  stridor,  the  rattle  of  the  mucous  and 
the  rigid  position  of  the  head. 

The  treatment  of  the  non-suppurative  stage  is  that  of  angina  in  general. 
Abscess  demands  immediate  incision,  either  with  an  ordinary  scalpel 
wrapped  with  adhesive  plaster  to  the  point,  or  with  a  special  knife  (Schmitz 
or  Carstens).  Perhaps  it  is  still  more  satisfactory  to  use  a  slender,  curved, 
sharp,  rat-toothed  forcep.  The  incision  is  made  with  the  guidance  of  the 
finger,  the  child  being  held  in  an  upright  position.  As  soon  as  pus  appears, 
the  body  should  be  bent  forward  to  prevent  aspiration  and  the  opening 
should  be  gradual!}71  increased.  This  does  not  insure  absolutely  against  an 
attack  of  asphyxia.  The  wound  usually  heals  rapidly  and  only  exception- 
ally will  it  be  found  necessary  to  reopen  it.  In  case  of  large  confluent  ab- 
scesses pointing  outward,  the  opening  should  be  made  from  without. 

Occasionally  a  chronic  tuberculous,  retropharyngeal  glandular  swelling, 
glandular  abscess  or  mediastinal  abscess,  due  to  gravitation,  may  occur. 
Their  treatment  is  that  of  tuberculosis  in  general.  Incisions  are  to  be 
avoided.  In  cases  with  symptoms  of  obstruction,  aspiration  with  a  syringe 
is  recommended.  Retropharyngeal  abscess  due  to  acute  osteomyelitis  of  the 
bodies  of  the  vertebrae  is  very  rare. 


254  TEXT-BOOK  OF  PEDIATRICS 

CONGENITAL  ANOMALIES  OF  THE  ESOPHAGUS 

The  congenital  anomalies  of  the  esophagus  are  chiefly  stenoses  or  atre- 
sias.  Congenital  atresia,  which  may  occur  in  many  different  forms,  as 
entire  absence  of  the  organ,  absence  of  the  upper  or  lower  portion,  a  cul-de- 
sac,  a  circular  closed  channel,  communication  with  the  trachea  or  bronchii, 
is  recognized  immediately  at  birth  by  the  fact  that  even  the  smallest 
quantity  of  nourishment  is  vomited  at  once  in  an  unchanged  condition. 
This  vomiting  may  occur  with  attacks  of  suffocation  which  lead  to  the 
conclusion  of  a  connection  between  the  esophagus  and  the  respiratory  pas- 
sages. The  esophageal  bougie  brings  up  against  an  impassible  barrier  at 
very  short  distance.  The  unsuccessful  attempt  to  aid  such  infants  by 
gastrostomy  has  always  proved  fatal.  The  rare  congenital  stenoses,  to  be 
differentiated  from  acquired  forms  by  the  fact  that  the  narrowed  portions 
show  a  normal  structure  of  the  connective  tissue,  may  exist  for  months  and 
years,  and  even  be  latent  until  old  agp.  Only  the  severe  forms  cause  symp- 
toms of  difficulty  in  swallowing,  gurgling  of  mucous,  rumination,  and 
temporary  occlusion.  The  bougie  shows  the  presence  of  an  obstruction. 
Congenital  diverticula  have  occasionally  been  reported. 

ACQUIRED  DISEASES  OF  THE  ESOPHAGUS 

Corrosive  Esophagitis. — Numerous  cases  of  burning  of  the  esophagus 
with  strong  acids  or  caustic  alkalies  (lye  and  soap  powders)  which  children 
have  swallowed  or  which  have  been  accidentally  administered  by  adults, 
still  occur.  The  action  of  the  caustic,  in  milder  forms,  is  shown  by  a  croup- 
ous  necrosis  of  the  epithelium  which  may  heal  without  scar  formation. 
With  more  severe  lesions,  the  entire  thickness  of  the  mucous  membrane  is 
eroded,  deep  sloughing  occurs,  followed  by  circumscribed  ulcers  which  may 
perforate.  Healing,  with  stricture-forming  cicatrices,  results. 

The  symptoms  of  corrosive  esophagitis  are  local  pain,  vomiting  of  bloody 
masses  and  pieces  of  the  mucous  membrane  even  to  the  extent  of  the  entire 
esophagus.  Added  to  these,  is  a  tendency  to  collapse.  Many  cases  end 
fatally,  while  in  others  convalescence  sets  in.  But  in  convalescence  a  new 
danger  threatens  at  the  end  of  several  days,  in  the  erosion  of,  and  hemor- 
rhage from  neighboring  blood-vessels,  perforation  with  mediastinitis,  and 
pyopneumothorax.  If  these  later  symptoms  do  not  occur,  those  of  stenosis 
may  appear  subsequently.  Of  those  poisoned  with  sulphuric  acid,  over 
one-half  die;  of  those  with  caustic  alkali,  one-fourth.  The  survivors  have 
strictures,  more  than  one-half  of  which  are  severe. 

The  stricture  is  usually  located  in  the  upper  third,  less  frequently  in  the 
middle  or  lower  third  of  the  esophagus.  Above  the  obstruction,  the  esoph- 
agus is  widened  and  hypertrophic,  the  mucous  membrane  being  fre- 
quently inflamed  and  covered  with  ulcerations.  The  nature  and  severity 
of  the  condition  depends  upon  the  grade  of  the  burning.  The  symptoms 
of  the  stricture  appear  two  or  three  weeks  after  the  poisoning  and  are 
those  of  obstruction  to  the  passage  of  the  swallowed  food. 

The  diagnosis  is  made  from  the  history  and  the  condition  of  the  cicatrix  is 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  255 

established  by  examination  with  the  sound  or  the  esophagoscope.  The 
prognosis  is  better  than  in  adults.  With  proper  treatment,  recoveries  are 
reported  in  from  fifty-six  to  sixty  per  cent,  of  the  cases. 

The  treatment  of  the  poisoning  consist  in  efforts  to  neutralize  the  caustic. 
Organic  acids,  chalk,  calcined  magnesia  are  employed;  carbonates,  because 
of  the  formation  of  CO2  gas,  should  not  be  used.  The  pain  may  be  controlled 
by  morphin  hypodermically  or  by  the  application  of  local  anesthetics 
(10  per  cent,  anesthesin  in  oil,  novocaine,  or  alypin,  2  per  cent,  solution 
5-10  drops).  Liquid  nourishment  should  be  given.  The  treatment  of  the 
sequelae  may  usually  begin  by  the  third  week  and  consists  in  gradual 
dilatation  with  the  bougie  and  of  injections  of  thiosinamin. 

Corrosive  esophagitis  with  its  sequelae  is  the  most  common  lesion  of  the 
organ  in  childhood.  All  other  conditions  are  great  rarities.  Cases  of  nervous 
cardiospasm,  with  symptoms  of  regurgitation  and  rumination,  as  well  as 
stenosis  following  syphilitic  ulcers,  are  known. 

NUTRITIONAL  DISTURBANCES  OF  INFANTS 

Introduction. — The  understanding  of  the  disease  conditions  discussed  in 
the  following  paragraphs  has  undergone  enormous  change  within  the  last 
three  decades.  Formerly  physicians  recognized  in  them  nothing  more  than 
diseases  of  the  stomach  and  intestine  which  could  be  considered  analogous 
to  the  fermentative  dyspepsia,  fermentative  catarrh,  gastro-enteritis  and 
diarrhoea  with  vomiting,  in  the  adult;  the  physiologically  slight  resistance 
of  the  infant  predisposing  it  to  a  severe  course.  Example  of  this  is  seen  in 
the  teaching  of  the  Vienna  school,  which  was  able  to  obtain  general  recog- 
nition through  the  classical  presentations  of  Widerhofer.  From  the  study  of 
anatomical  findings,  this  school  distinguished  severally,  the  purely  func- 
tional, the  catarrhal,  and  the  inflammatory  ulcerative  lesions  of  the  intes- 
tine ;  each  of  which  could  be  recognized  clinically  by  the  varying  consistence 
"  of  the  stools  and  the  degree  of  constitutional  disturbance.  This  conception 
further  enabled  these  authorities  to  recognize  (1)  acute  and  chronic  dys- 
pepsia, as  subdivisions  of  the  purely  functional  disturbances;  (2)  histologi- 
cally  and  clinically  severe  entero-catarrh ;  (3)  follicular  enteritis  chiefly  of 
the  large  intestine,  belonging  to  the  inflammatory  type  and  (4),  the  extreme 
form  of  entero-catarrh,  formerly  known  as  cholera  infantum,  as  final  sub- 
division of  this  group. 

Useful  as  this  system  was  in  its  time  and  excellent  as  the  observations 
were  upon  which  it  was  based,  further  advance  of  knowledge  has  made  its 
abandonment  necessary.  With  great  difficulty  could  cases  in  actual  prac- 
tice be  classified  under  these  sharply  differentiated  forms  of  disease,  in 
view  of  the  frequent  occurrence  of  intermediate  and  transitional  forms.  In 
infancy,  inflammatory  conditions  occurred  which  resembled  the  intestinal 
affections  of  the  adult;  but  these,  again,  were  greatly  exceeded,  alike  in 
frequency  and  importance,  by  disturbances  which  had  to  be  considered 
purely  functional.  Identical  and  entirely  normal  findings  in  the  bowel  were 
shown  in  cases  presenting  the  most  variable  clinical  symptoms  in  which, 
according  to  previously  accepted  teachings,  severe  anatomical  lesions  were 


256  TEXT-BOOK  OF  PEDIATRICS 

to  be  expected.  It  has  become  clear  that  in  infancy,  as  in  later  life,  func- 
tional alterations  of  the  gastro-intestinal  system  underlie  pathological 
conditions,  but  these,  in  the  infant  organism,  give  rise  to  so  many  and  such 
important  changes  in  the  general  health  that  we  may  no  longer  speak  of  them 
as  merely  organic,  but  rather  as  general  diseases;  and,  further,  as  general 
diseases  so  exceedingly  grave  that  frequently  the  entire  symptom-complex 
is  characteristic  of,  and  the  prognosis  dependent  upon  the  constitutional 
status  rather  than  upon  the  intestinal  lesion.  Again,  it  has  been  found 
that  the  bacteriolcgic  etiology  of  these  diseases  does  not  play  the  essential 
role  formerly  attached  to  it.  Both  acute  and  chronic  disorders,  either  of  the 
mildest  or  the  most  severe  form,  may  be  of  purely  alimentary  origin,  and 
numerous  diagnostic  symptoms,  formerly  supposed  to  be  caused  by  bacterial 
toxins,  may  be  the  results  of  a  direct  food  poisoning.  In  a  word,  disturb- 
ances created  by  intestinal  lesions  are  commonly  seen  to  induce  so  complete 
and  so  severe  derangement  of  the  entire  metabolic  process  that  the  term 
gastro-intestinal  disease  has  become  too  narrow.  In  its  place  has  appeared 
the  phrase  "disturbance  of  nutrition."1 

In  view  of  this  conception  the  necessity  of  distinguishing  the  nutri- 
tional disturbances  of  the  breast-fed  infant  from  those  of  the  artificially-fed 
at  once  becomes  obvious.  The  very  feeding  of  a  food  other  than  that  in- 
tended for  the  infant  by  nature  is  a  pathologic  condition.  Such  feeding 
lowers  the  resistance  and  may  very  readily  be  the  cause  of  disease.  Only 
rarely  does  the  bottle-fed  infant  thrive  anywhere  near  as  well  as  the  breast- 
fed. The  tendency  to  rickets,  spasmophilia  and  anemia  is  very  great.  The 
immunity  against  infection  is  reduced  and  the  tendency  to  the  conditions, 
to  be  discussed  i.  e.,  the  disturbances  of  nutrition,  is  exceptionally  great. 

DISTURBANCES  OF   NUTRITION  OF  THE   ARTIFICIALLY- 
FED  INFANT      . 

GENERAL  ETIOLOGY  AND  PATHOGENESIS 

1.  Milk. — The  increased  tendency  to  disease,  and  the  actual  causation  of 
disease  in  infants  fed  upon  milk  other  than  that  intended  for  them  in  the 
natural  process  of  nutrition,  i,  e.,  mother's  milk,  is  not  dependent  to  any 
great  extent  upon  such  accidental  factors  as  the  bacterial  contamination  of 
the  milk  or  the  improper  combination  of  the  food  elements,  etc.  It  may  be 
accepted  as  proved,  rather,  that  this  tendency  to  and  actual  increase  in  the 
morbidity  of  bottle  babies  is  due  primarily  to  the  milk  itself,  simply  because 
it  is  not  suitable  for  the  human  young,  falling  short  in  many  essential 
requirements.  The  morbidity  is  exceedingly  great  even  in  those  artificially- 
fed  infants  in  whose  feeding  no  criticism  can  be  brought  against  the  technic 
or  the  food  mixture.  For  an  explanation  we  must  accept  the  theory  that  the 
specific  peculiarities  of  cow's  milk  are  directly  or  indirectly  the  causative 
factor.  And  this  brings  us  to  the  outstanding  problem  of  all  artificial 
feeding,  i.  e.,  what  is  there  in  cow's  milk  which,  though  it  be  modified  to 
resemble  mother's  milk  in  every  respect,  still  leaves  it  so  inadequate  a  food 
for  the  human  young? 

1  Ernaehrung  Stoerung,  Czerny. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  257 

The  first  attempts  at  explanation  were  made  by  Biedert  when  he  put 
forth  the  proposition  of  the  indigestibility  of  the  casein  of  cow 's  milk.  He 
claimed  that  the  absorption  of  the  products  of  protein  digestion  was  very 
poor  in  the  bowel  and  this  formed  the  basis  for  the  injury.  At  present,  this 
explanation  seems  to  be  successfully  controverted  by  the  consistent  findings 
of  more  careful  chemical  examination  of  the  stools,  the  digestive  processes  in 
the  intestine,  metabolism  experiments  and  clinical  observation.  Similarly 
the  theory  of  Hamburger  that  the  injury  is  due  to  toxicity  of  the  foreign 
protein  is  not  born  out  clinically.  Indeed,  no  definite  proof  has  been 
brought  forward  to  show  that  the  protein  is  the  prime  factor  in  the 
etiology.  There  is  no  doubt,  however,  that  fat  and  sugar  have  a  harm- 
ful action.  But  even  these  substances  are  not  primarily  the  cause  of 
the  nutritional  disturbance  except  when  fed  in  improper  dosage.  This  fact 
is  demonstrated  by  the  more  recent  researches,  which  show  that  by  chang- 
ing certain  other  constituents  of  the  food,  as  for  instance;  increasing  the 
percentage  of  protein,  reducing  the  amount  of  whey  or  replacing  the  carbo- 
hydrate by  one  less  fermentible,  immediately  relieves  the  disturbance. 
Others  have  attempted  to  show  that  the  injurious  factor  lay  in  certain 
chemically  undemonstrable  substances  in  the  whey.  According  to  Schloss, 
it  is  hardly  probable  that  the  whey  has  a  distinctly  injurious  action  on  the 
intestinal  function.  According  to  the  theories  of  Marian,  Concetti,  Escherich, 
Pfaundler  and  others,  the  great  advantage  of  breast-milk  is  due  to  cer- 
tain specific  ferment-like  substances  which  act  as  a  stimulant  to  growth 
and  development.  The  absence  of  such  substances  in  cow's  milk  or  rather, 
the  fact  that  these  substances  in  the  milk  of  various  species  are  not  inter- 
changeable is  the  cause  of  the  failure  of  artificial  feeding.  If  these  substances 
are  contained  in  the  whey,  the  deleterious  action  of  whey  is  easily  explained. 
Even  without  bringing  to  our  aid  the  theory  of  such  hypothetical  ferments, 
it  can  be  conceived  readily  that  the  physical  and  biochemical  structure 
of  the  whey  of  cow's  milk  is  such  as  to  make  it  a  fluid  in  which  the  digestive 
function  of  the  intestinal  mucosa  is  much  more  difficult  than  in  the  medium 
of  breast-milk,  which  also  has  a  certain  catalytic  action  (Finkelstein  and 
Meyer).  Strong,  lusty  infants  can  call  up  the  reserve  strength  necessary  to 
overcome  this  hampered  action  of  the  digestive  apparatus,  while  weak 
infants  succumb. 

Some  authors  do  not  believe  in  the  theory  which  blames  the  injury  to  the 
specific  action  of  any  one  foreign  substance  in  the  milk,  but  lay  the  difficulty 
to  the  varying  relation  of  organic  and  inorganic  components. 

2.  Tolerance. — In  infants  with  strong  metabolic  powers,  overfeeding 
will  cause  merely  an  excess  of  fat  (Fig.  72)  which  can  hardly  be  rated  as  a 
disease.  Very  commonly  the  symptom  of  excessive  fat  is  combined  with 
manifestations  of  rickets,  spasmophilia  or  exudative  diathesis.  Very  few 
infants,  however,  have  a  digestive  system  which  will  withstand  overfeeding 
for  any  length  of  time;  signs  of  dystrophy  or  dyspepsia  supervene  and,  if  the 
excess  of  food  be  continued,  even  more  serious  conditions  result.  In  some 
cases,  indeed,  the  actual  excess  of  food  does  not  have  to  be  so  very  great, 
for  there  are  infants  that  become  ill  when  the  amount  of  food  does  not  sur- 
17 


258 


TEXT-BOOK  OF  PEDIATRICS 


pass  or  is  below  the  physiologic  requirement.  Such  infants  may  be  said  to 
have  a  low  tolerance.  This  injurious  excess  may  be  due  to  too  great  volume 
of  a  properly  modified  food  as  is  seen  in  the  " overfeeding  dyspepsia"  of  the 
breast-fed  infant  or  it  may  be  due  to  too  much  of  one  ingredient  in  the 
mixture.  The  injuries  of  high  sugar  or  high  flour  feeding  serve  as  examples 
of  the  latter. 

3.  Composition  of  the  Food. — Closely  related  to  the  above  category  of 
causes  of  nutritional  disturbances  is  that  group  in  which  an  improper  rela- 


FIG.  72. — Adiposity  in  an  overfed  eight-month-old  child, 
weight  9.4  kilos  (21  pounds).  (Gisela  Children's  Hospital, 
Munich,  Prof.  Ibrahim.) 

tive  balance  of  the  individual  food  components  forms  an  essential  factor; 
"  nutritional  disturbance  ex  correlatione. "  The  correlation  of  the  ingredients 
of  cow 's  milk  are,  in  themselves,  not  adapted  to  the  infant.  In  addition  to  this 
the  infant  is  rarely  fed  with  natural  cow 's  milk  but  with  cow 's  milk  to  which 
innumerable  other  things,  such  as  water,  flour,  fat  and  various  carbohy- 
drates, have  been  added.  As  a  result,  the  correlation  of  the  elements  of  the 
food  becomes  even  more  abnormal  and  resultingly  more  liable  to  produce 
disturbances.  Such  an  etiology  is  probable,  for  example,  in  those  cases  in 
which  a  persisting  dyspepsia  is  relieved  by  the  addition  of  a  small  amount  of 
casein  to  the  formula  without  other  change.  Or  in  the  reverse,  infants  that 
have  not  thrived  may  be  made  to  develop  normally  by  reducing  the  milk 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  259 

and  increasing  the  carbohydrate.  Very  slight  changes  in  the  correlation 
may  cause  marked  changes  in  the  nutritional  status  of  the  infant  either  for 
better  or  for  worse. 

According  to  our  present  conception,  the  transition  from  the  tendency 
to  disease,  to  disease  itself,  results  from  a  disproportion  of  the  demand  upon, 
and  the  ability  of,  the  metabolic  functions  leading  to  irregularities  of  the 
digestive  and  resorptive  powers  which  in  turn  results  in  pathologic  bacterial 
growth  and  putrefactive  or  fermentative  processes.  This  adds  a  new  fac- 
tor to  the  complex  for  harm  in  the  shape  of  changed  endogenous  fermenta- 
tion. According  to  Moro,  Tobler  and  Bes-sau  the  ascent  of  this  fermentative 
process  into  the  normally  almost  sterile  small  intestine  is  of  greater  impor- 
tance than  the  increase  of  this  process  in  the  large  bowel.  For  here,  at  the 
very  seat  of  the  digestive  function,  slight  changes  in  the  chemical  process 
are  greatly  magnified  in  their  importance  to  the  organism.  The  form  of  the 
decomposition  depends  largely  upon  the  composition  and  correlation  of  the 
food.  Usually  the  disturbance  affects  the  digestion  of  the  fat  and  carbo- 
hydrate. This  results  in  the  formation  of  acids  of  fermentation  which  are 
usually  looked  upon  as  pathogenetic  of  these  conditions.  Recently  several 
authors  have  added  to  this  " fermentation  injury,"  the  conception  of  a 
"putrefaction  injury"  which  is  caused  by  an  excessive  decomposition  of 
protein  on  the  basis  of  the  acid  formation  (fat  and  sugar).  This  condition  is 
supposed  to  cause  diarrhoea  and  other  symptoms  of  bowel  irritation  in  its 
acute  form.  In  its  chronic  form  it  is  characterized  by  far  reaching  general 
manifestations  and  putrefactive  stools. 

4.  Inanition. — Underfeeding  also  plays  an  important  role  in  the  causa- 
tion of  nutritional  disturbances.    New-born  infants  are  often  greatly  under- 
fed because  of  the  fear  that  a  cow 's  milk  mixture  might  be  harmful,  and  for 
the  same  reason  children  with  intestinal  disturbances  are  often  underfed 
for  a  long  time.    Aside  from  simple  underfeeding,  that  is  the  feeding  of  a 
perfectly  satisfactory  food  in  too  small  amount,  we  must  also  consider 
qualitative  underfeeding.    This  condition  obtains  when  the  caloric  require- 
ment is  fully  covered,  but  one  or  more  essential  elements  of  the  diet  are 
below  requirement.    Normal  development  can  occur  only  when  the  require- 
ment of  every  food  element  including  the  inorganic  substances  is  fulfilled. 
Frequently  quantitative  and  qualitative  inanition  may  be  combined  as  in 
the  continued  feeding  of  thin  gruels. 

The  usual  results  of  moderate  inanition  are  failure  to  gain  in  weight  or 
slight  gradual  losses.  Persisting  inanition  leads  to  subnormal  temperature 
and  slowing  of  the  pulse.  The  condition  may  be  quickly  relieved  in  the  early 
stages  by  the  addition  of  liberal  amounts  of  suitable  food.  In  the  cases  of 
long  standing,  however,  the  tolerance  is  markedly  lowered  and  any  sudden 
increase  of  food  may  bring  on  extreme  diarrhoea  and  toxic  manifestation 
and  death.  In  new-born  and  young  infants,  inanition  may  cause  vomiting 
and  frequent  loose  bowel  movements,  a  hunger  dyspepsia. 

5.  Infection.— In  contrast  to  the  etiologic  factors  of  disturbances  of 
nutrition  of  purely  alimentary  origin  and  without  other  provocative  influ- 
ences, we  have  another  category  of  nutritional  disturbances  which  must  be 


200  TEXT-BOOK  OF  PEDIATRICS 

considered  as  secondary  to  other  forms  of  injury  to  the  general  infantile 
organism  and  affecting  the  gastro-intestinal  function  especially.  The 
digestion  is  so  definitely  injured  that  food  which  was  well  accepted  can  no 
longer  be  borne.  This  form  of  reduction  of  the  tolerance  as  a  result  of  exo- 
genous weakening  may  be,  to  a  certain  extent,  contrasted  directly  with  the 
reduction  of  tolerance  by  excess  feeding.  The  most  characteristic  member 
of  this  group  is  the  disturbance  of  nutrition  resulting  from  acute  or  chronic 
infection.  The  bacterial  poisons  injure  the  entire  cell  structure  of  the  body 
and,  of  course,  this  also  affects  the  organs  of  digestion.  As  a  result  their 
functional  capacity  is  reduced,  and,  unless  the  food  is  promptly  changed  to 
meet  the  altered  tolerance,  a  complicating  alimentary  disturbance  is  added 
to  the  infectious  process.  The  complication  may  become  grave  enough  to 
govern  the  entire  clinical  picture  and  obscure  the  original  infection.  Recov- 
ery from  the  nutritional  disturbance  may  take  place  before  the  infectious 
process  disappears  or  the  two  may  be  relieved  coincidently  or,  finally,  the 
digestive  trouble  may  persist  and  become  chronic  as  an  independent  disease. 

6.  Milk  Infection  and  Milk  Toxins. — The  etiology  of  a  nutritional  dis- 
turbance caused  by  the  bacterial  content  of  milk  or  by  milk  toxins  is  identi- 
cal with  that  of  the  condition  above.  Formerly  the  bacterial  content  of 
cow's  milk  or  the  chemical  products  of  their  activity  before  ingestionwas 
held  to  be  the  chief  etiologic  factor  in  the  digestive  disturbances  of  artifi- 
cially-fed infants.  At  present,  however,  but  slight  stre?s  is  laid  upon  this 
phase.  The  majority  of  milk  bacteria  are  harmless  saprophytes,  which  may 
be  ingested  in  large  quantities  without  harm.  It  must  be  admitted  that 
pathogenic  organisms  are  sometimes  found  in  dirty  milk.  Furthermore,  in 
weak  infants  fermentation  processes  occur  more  readily  if  huge  numbers  of 
fermentation  producing  organisms  are  added  to  intestinal  flora,  than  when 
the  food  is  sterile.  It  is  also  possible  that  injury  may  come  from  substances 
occurring  in  the  milk  as  a  result  of  improper  feeding  of  the  animals,  or  from 
the  products  of  decomposition  of  the  milk  such  as  acids,  peptones,  etc.  This 
possibility  is  limited,  however,  by  the  fact  that  if  these  substances  occur  in 
any  appreciable  amount,  the  taste,  odor  and  even  appearance  of  the  milk 
are  such  that  the  mother  will  not  use  it  or  the  child  itself  will  refuse  it. 

Until  recently,  two  important  points  of  argument  Avere  urged  in  favor  of 
the  etiologic  relation  of  the  contaminated  milk,  viz.,  (1)  the  increase  of 
gastro-intestinal  disease  and  of  the  death-rate  from  this  cause  in  the  hot 
months  of  the  year  (the  summer  apex  of  infant  mortality) ;  and  (2)  the  fact 
that  these  prevalent  conditions  affect  principally  artificially-fed  infants  while 
breast-fed  babies  remain  almost  wholly  immune.  The  parallel  between  the 
statistical  evidence  and  the  increase  in  the  contamination  of  milk  during  the 
summer  months  appeared  to  be  undeniable  evidence  of  the  serious  patho- 
genicity  of  spoiled  food.  At  present,  however,  even  this  conclusion  is  denied 
and  there  is  an  inclination  to  accept  a  belief  in  the  harmful  influence  of  heat 
upon  the  child,  although  the  exact  nature  of  this  influence  has  not  yet  been 
determined.  In  some  cases  the  summer  heat  may  cause  overheating 
(hyperthermia)  producing  disease  and  death  which  may  be  considered 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  261 

closely  related  to  the  phenomena  of  heat  stroke.  Such  disease  begins  sud- 
denly and  runs  an  acute  or  subacute  course,  characterized  symptomati- 
cally  by  convulsions  and  hyperpyretic  coma.  The  conditions  may  be 
prevented  or  cured  by  the  prompt  application  of  fever-reducing  measures. 
La  other  cases,  the  gradual  effect  of  the  summer  heat  is  to  reduce  the  limit 
of  tolerance,  so  that  alimentary  disorders  occur  very  readily  and  tend  to 
run  an  especially  severe  course.  Moreover,  bacterial  infection,  entering 
through  the  =kin  eroded  by  excessive  perspiration,  appears  to  play  an  impor- 
tant role  during  the  hot  weather  and  death  may  frequently  occur  through 
such  an  intercurrent  invasion  of  pathogenic  bacteria.  Not  until  we  have 
eliminated  all  these  causes  may  we  entertain  the  etiologic  relations  to  sum- 
mer diseases  of  contaminated  milk. 

A  plausible  explanation  of  the  immunity  of  breast-fed  infants  from  heat 
injury  is  also  suggested.  It  appears  that  an  infant  with  impaired  nutri- 
tion is  much  less  resistant  of  heat  influences  than  the  normal  babe.  Since 
most  breast-fed  infants  are  well  and  veiy  many  artificially-fed  babies  have 
some  slight  disturbance  of  nutrition,  the  difference  in  the  effects  of  heat  is 
possibly  explained. 

In  considering  the  relationship  between  high  temperature  and  infant 
mortality,  the  prevailing  custom  of  burdening  young  children  too  heavily 
with  clothing  may  add  to  the  injuries  caused  by  the  heat  of  summer.  How 
and  to  what  extent  these  several  factors  of  diminished  tolerance  produce 
secondary  disturbances  of  nutrition,  is  again  a  question  of  relation  between 
the  degree  of  resistance  and  the  strength  of  the  attacking  forces.  In  feeble 
children  or  in  children  weakened  in  any  way,  especially  in  those  with  im- 
paired nutrition,  a  slight  overheating,  a  coryza,  a  small  phlegmon,  or  a 
vaccination,  may  give  rise  to  serious  symptoms.  A  healthy,  normal  child, 
on  the  contrary,  may  resist  even  severe  infection,  without  the  appearance 
of  any  gastro-intestinal  disorder. 

7.  Constitutional  Anomalies. — There  are  infants  that  will  thrive  on  any 
form  of  artificial  food  and  apparently  never  have  a  nutritional  disorder 
even  though  subjected  to  severe  infections.  Others  require  the  most  exact- 
ing study  of  the  feeding  formula,  are  extremely  prone  to  intestinal  and  nutri- 
tional disturbances,  their  nutritional  function  suffering  severe  upsets  as  a 
result  of  the  mildest  infection.  Every  podiatrist  sees  children  that  are 
extremely  hard  to  raise  because  they  respond  to  the  slightest  irregularities 
of  the  food  or  to  every  mild  infection  with  the  most  stormy  general  symp- 
toms. These  differences  in  the  nature  of  the  individual  can  be  explained 
only  on  the  basis  of  a  congenital,  constitutional  tendency  that  acts  in  the 
form  of  a  greater  or  lesser  tolerance.  We  have  no  definite  knowledge  of  the 
basic  etiology  of  such  a  constitutional  difference  and  no  great  advance  in  the 
understanding  is  made  by  looking  upon  it  as  a  manifestation  of  '"neuro- 
pathy" or  "hypersensibility"  or  as  a  part  of  the  "exudative  diathesis." 
It  seems  more  satisfactory  to  consider  the  one  group  as  "trophostabile" 
and  the  other  as  "tropholabile"  and  leave  further  discussion  for  a  time 
when  more  study  has  given  a  clear  understanding. 


262  TEXT-BOOK  OF  PEDIATRICS 

GENERAL  SYMPTOMATOLOGY 

It  has  been  shown  in  the  introduction  to  the  Chapter  on  the  Disturbances 
of  Nutrition  that  symptoms  of  these  conditions  may  be  much  more  varied 
than  has  been  hitherto  supposed.  To  appreciate  the>  complexity  of,  this 
symptomatology,  we  must  recall  the  several  phases  of  the  process  of  nutri- 
tion. It  Includes  not  only  the  digestion  and  the  absorption  of  food  from  the 
bowel,  its  assimilation,  the  repair  of  the  waste  of  tissue  incident  to  func- 
tional activity,  and  the  process  of  growth,  but  also  the  maintenance  of  the 
normal  concentration  of  the  tissue-cells,  the  function  of  internal  secretion 
and  the  regulation  both  of  heat  production  and  of  heat  loss.  Accordingly 
the  symptoms  of  nutritional  disturbance  are  not  confined  to  pathologic 
alterations  in  the  gastro-intestinal  tract,  to  loss  of  body-weight,  or  to  an 
arrest  of  growth.  It  is  to  be  expected  that  variations  of  body-temper- 
ature and  perversions  of  function  in  many  different  organs  will  be  met 
with.  The  relationship  of  such  symptoms  to  disturbances  of  nutrition  is 
shown  in  the  fact  that  they  are  often  favorably  influenced  by  changes  in  the 
form  of  feeding.  There  is  a  type  of  alimentary  fever  which  disappears 
almost  immediately  when  feeding  is  discontinued;  an  albuminuria  of 
similar  origin,  and  even  cerebral  and  spinal  symptoms,  with  anomalies  of 
cardiac  and  pulmonary  function,  which  may  be  relieved  at  once  by  changes 
in  diet. 

Recognition  of  the  symptoms  of  disturbances  of  nutrition  presupposes  a 
knowledge  of  the  "  normal  conditions  of  nutrition  and  of  the  normal  meta- 
bolic processes." 

As  superficial  evidences  of  normal  health  may  be  noted :  the  proper  devel- 
opment of  the  musculature  and  the  fat  layers  of  the  body,  the  turgor  of  the 
skin  and  the  skeletal  tissues,  and  the  normal  color  of  the  skin  and  visible 
mucous  membranes.  Broadly  speaking,  health  means  the  normal  func- 
tioning of  all  organs,  and  particularly  of  the  kidneys,  lungs,  heart  and  ner- 
vous system;  a  general  development  proportional  to  age;  and  a  due  degree  of 
agility  and  of  static  and  dynamic  power. 

As  indications  of  especial  bearing  upon  nutritional  integrity,  the  normal 
activity  of  the  gastro-intestinal  tract,  the  proper  adjustment  of  body- 
temperature,  a  progressive  increase  in  weight  and  the  maintenance  of 
natural  immunity  may  be  cited. 

With  a  fairly  equable  atmospheric  temperature,  the  curve  of  body-tem- 
perature of  the  infant  is  remarkable  for  its  slight  variations  (monothermia). 
The  weight-curve  shows  the  same  continuity.  So  small  variations  are  seen 
with  daily  weighings  that  the  curve  shows  an  almost  evenly  rising  line. 
The  active  formation  of  antibodies  is  to  be  recognized  by  the  infrequency 
of  infections  and  their  ordinarily  mild  course. 

As  a  final  and  a  most  important  indication  of  normal  nutrition,  we  note 
the  standard  of  tolerance  for  food;  meaning  thereby  the  exercise  of  a  wide 
range  of  tolerance  toward  the  food-stuffs  ingested.  This  tolerance  is 
exhibited  in  two  ways;  in  the  quick  adaptation  of  the  unimpaired  digestive 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  263 

functions  to  increased  quantities  of  food  without  consequent  harm,  a 
quantitative  normal  tolerance;  and  in  the  successful  response  to  food  in  the 
most  varied  mixtures,  whether  of  mother's  milk  or  cow's  milk,  whether  in 
preparations  rich  in  fat  and  poor  in  carbohydrates  or  vice  versa,  in  so  far 
as  they  are  adapted  to  continuous  feeding.  This  response  may  be  denned 
as  the  normal  reaction  to  food. 

Equally,  the  healthy  child  exhibits  a  normal  reaction  to  and  endurance 
of  those  external  influences  which  tend  to  reduce  tolerance;  e.  g.,  in  the  large 
measure  of  resistance  it  shows  to  infectious  disease  or  to  abnormal  tempera- 
ture changes,  to  which  it  does  not  succumb  unless  the  attack  from  without 
is  more  than  ordinarily  severe. 

On  the  other  hand,  symptoms  of  disturbance,  in  the  direction  of  lowered 
nutrition,  are  seen  in  loss  of  weight,  emaciation,  increased  or  diminished 
tonus,  abnormal  dryness  or  increased  fluidity  of  the  tissues,  and  pallor  or 
injection  of  the  sldn  and  mucous  membranes.  Numerous  signs  of  functional 
insufficiency  are  shown  in  the  form  of  muscular  weakness,  decreased  or 
increased  nervous  irritability,  the  disordered  functional  activity  of  various 
important  organs,  and  especially  of  the  nervous  system.  Important  indi- 
cations of  pathologic  changes  in  the  gastro-intestinal  tract  are  to  be  found  in 
an  abnormal  curve,  characterized  by  slow  rises  and  frequent  drops,  in 
abnormal  temperature  changes,  and  in  the  lowering  of  the  power  of  resis- 
tance to  bacterial  infections. 

It  should  be  observed  that  either  subnormal  temperature  or  fever  may 
be  caused  by  dietetic  disturbances.  Fever  is  frequently  associated  with 
other  symptoms  characteristic  of  fevers  due  to  infections  such  as  cardiac 
weakness,  albuminuria,  leucocytosis,  etc.  " Alimentary  fever"  or  "dietary 
toxemia"  can  be  distinguished  from  the  results  of  infection  only  by  their 
etiology  and  by  their  quick  response  to  changes  in  diet. 

Different  combinations  of  the  symptoms  briefly  described  above,  and 
variations  in  their  course  give  us  clinical  pictures,  and  sometimes  symptom- 
complexes  of  contrasting  significance.  The  form  which  any  individual  case 
may  take,  whether  indicated  by  arrest  of  development  and  loss  of  weight  or 
by  symptoms  resembling  acute  toxemia,  depends  largely  upon  the  kind  and 
amount  of  food  given.  Infants  with  a  primarily  high  tropholability  and 
infants  severely  injured  by  alimentary  or  infectious  'processes  react  more 
definitely  to  the  influences  which  cause  only  mild  disturbances  in  children 
less  liable,  influences  which  in  strong  infants  may  even  be  favorable.  This 
peculiar  irritability  in  response  to  food  and  other  stimuli  is  known  as  the 
paradoxical  reaction. 

The  reduction  of  the  tolerance  is  not  only  shown  by  the  variation  in  the 
metabolism  but  is  reflected  in  an  unusual  susceptibility  to  external  influ- 
ences. In  such  patients,  infection  occurs  more  readily  and  tends  to  serious 
results,  or  minor  ailments  now  readily  lead  to  secondary  disturbances  of 
nutrition.  Summer  heat  or  excessive  artificial  temperature  produces  vari- 
ations in  body-temperature  or  other  disease  symptoms  which  may  as- 
sume a  severe  type. 


264  TEXT-BOOK  OF  PEDIATRICS 

CLASSIFICATION 

The  classification  of  disturbances  of  nutrition,  into  acute  and  chronic 
dyspepsia  (the  latter  also  called  atrophy),  entero-catarrh,  cholera  infantum 
and  enteritis,  until  recently  accepted,  is  no  longer  tenable.  Since  it  has 
become  apparent  that  in  these  several  conditions  we  have  but  variant  forms 
and  degrees  of  general  alimentary  disorder,  and  since  it  is  known  that  one 
form  may  be  transformed  into  another  form  by  changes  in  diet,  it  is  no 
longer  fitting  to  use  terms  which  bring  the  intestinal  symptoms  into  the  fore- 
ground and,  at  the  same  time,  encourage  the  view  that  each  is  to  be  looked 
upon  as  a  distinct  disease. 

The  classification  of  Czerny  and  Keller  gives  the  alimentary  element  in 
the  disturbance  its  proper  place.  It  distinguishes  (a)  disturbances  of 
nutrition  due  to  food  (6)  disturbances  due  to  infection,  and  (c)  those  due  to 
congenital  constitutional  defects.  Under  the  first  class,  we  have  as  sub- 
classes, the  various  "food  injuries,"  such  as  those  caused  by  an  excess  of 
milk  or  of  flour.  Under  the  second,  disorders  due  to  contaminated  milk  and 
diseases  due  to  enteral  and  parenteral  infection,  such  as  dyspepsia  or  chol- 
era infantum  under  the  older  classification.  Under  the  third,  the  diatheses 
associated  with  the  nutritional  problem. 

The  authors  are  convinced  that  an  etiologic  classification  is  not  only 
unessential  but  impossible.  In  the  group  as  a  whole,  and  even  more  so  in  the 
individual  case,  the  causation  is  not  clearly  recognizable  nor  devisible into  its 
separate  factors.  Take,  for  instance,  the  child  that  does  not  thrive  on  a 
cow's  milk  mixture,  with  the  result  that  the  immunity  is  decidedly  reduced. 
To  this  primary  nutritional  abnormality  add  an  infection  which  will  bring 
on  manifestations  of  dyspepsia.  In  this  case  it  is  obviously  impossible  to 
lay  the  cause  to  any  one  definite  etiologic  factor.  In  chronic  cases  leading 
gradually  to  atrophy,  all  sorts  of  etiologic  factors  have  come  into  play, 
either  together  or  in  sequence,  so  that,  again,  a  systematic  classification  is 
impossible.  These  difficulties  are  avoided  if  we  accept  a  simple  clinical 
grouping  such  as  the  following. 

A.  Nutritional  disturbances  without  toxic  manifestations. 

I.  Dystrophy.1    Disturbance  of  qualitative  and  quantitative  growth. 

(a)  Without  diarrhoea,  or  slight  diarrhoea. 

1.  Dystrophy  as  a  result  of  excessive  milk  feeding  (the  milk- 
feeding  injury  of  Czerny  and  Keller). 

2.  Dystrophy  as  a  result  of  excessive  flour  feeding  (the  flour- 
feeding  injury  of  Czerny  and  Keller). 

3.  Dystrophy  as  a  result  of  inanition. 

(b)  With  diarrhoea. 

4.  Dystrophy  with  dyspepsia  (chronic  dyspepsia). 

irThe  authors  have  replaced  the  older  term  "Disturbance  of  balance"  by  that  of 
"Dystrophy"  which  seems  to  bring  out  the  changes  noted  in  the  clinical  picture  and 
especially,  the  delayed  development  more  clearly.  Langstein  suggests  the  term  "hypo- 
trophy"  but  this  is  almost  synonymous  with  the  term  "hypoplasia"  which  refers  rather 
to  a  failure  of  the  germ  cell. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  265 

II.  Decomposition,  loss  of  body-weight  as  a  result  of  imbalance  of 
the  metabolic  processes  with  the  loss  of  essential  body  elements, 
especially  water,  because  of  the  advanced  degree  of  alimentary 
and  dyspeptic  injury. 
B.  Nutritional  disturbances  with  toxic  manifestations. 

I.  Acute  dyspepsia;  acute  gastro-intestinal  disturbance  resulting 
from  abnormal  endogenous  decomposition  of  the  food,  character- 
ized by  free  purgation  and  leading  to  intoxication. 

II.  Intoxication,  severe  general  disturbance  of  a  toxic  nature  with 
terrific  losses  of  weight,    probably  the  result   of   poisoning  by 
intermediate  products  of  metabolism  in  combination  with    se- 
vere dehydration. 

It  is  hardly  necessary  to  say  that  the  individual  headings  in  each  group 
do  not  represent  definitely  separable  disease  entity  in  each  case.  They 
should  be  considered  rather  as  various  stages  which  may  at  any  time  progress 
from  the  milder  to  the  more  severe.  Such  transition  may  take  place  if  the 
food  is  changed  or  if  the  patient  be  subjected  to  an  external  injury  which 
reduces  his  resistance. 

A.  NUTRITIONAL  DISTURBANCES  WITHOUT  Toxic  MANIFESTATIONS. 

I.  Dystrophy, 
(a)  Without  diarrhoea. 

1.  Dystrophy  as  a  result  of  excessive  milk  feeding.     (Milk-feeding 
injury  of  Czerny  and  Keller.    Mild  form  of  atrophy.) 

Symptoms. — This  condition  is  characterized  chiefly  by  delayed  develop- 
ment both  in  a  qualitative  and  quantitative  way  without  other  distinct 
indications  of  illness. 

Even  at  the  outset,  daily  weighings  show  great  variations,  both  upward 
and  downward,  so  that  the  curve  becomes  very  irregular.  Later,  periods  of 
variable  duration  occur  in  which  there  is  no  change  of  weight  or  a  continuous 
loss,  again  equalized  by  a  rise  (Fig.  73).  On  the  whole,  the  weight  falls 
gradually  below  the  normal  average  and,  although  not  actually  emaciated, 
the  child  gives  the  impression  of  great  debility.  Retardation  of  growth  is 
noticeable,  so  that  the  infant  is  generally  smaller  than  a  healthy  child  of  the 
same  age. 

The  evidences  of  reduction  in  the  qualitative  conditions  of  nutrition  are 
to  be  especially  noted.  The  tone  of  the  tissues  is  reduced,  the  muscles  are 
relaxed,  the  abdomen  is  distended,  the  skin  dry,  the  color  pale,  dynamic  and 
static  power  are  below  the  standard  to  be  looked  for  at  the  given  age. 
Disposition  and  sleep  are  affected.  The  reduction  of  immunity  is  seen  in 
the  tendency  to  secondary  infections,  chiefly  of  the  skin,  which  donot  usually 
extend  beyond  their  local  limits. 

The  stools  may  be  normal  or,  again,  dryer  and  lighter  than  usual,  or 
even  white  in  color.  Rarely  do  we  see  the  fat-soap  stools,  the  so-called 
"gray  obstipation."  The  temperature  is  more  variable  than  in  health. 
With  the  exception  of  the  meteorism  and  occasional  vomiting,  other  evi- 
dences of  disease  of  the  gastro-intestinal  tract  are  absent. 


266 


TEXT-BOOK  OF  PEDIATRICS 


Etiology. — The  origin  of  the  condition  described  lies  solely  and 
primarily  in  an  excess  of  milk  in  the  diet  with  an  insufficiency  or  absence 
of  carbohydrate.  In  many  cases  the  milk  was  given  in  too  large  amounts; 
in  others,  the  error  in  the  diet  appears  after  a  short  time  even  though  the 
food  was  apparently  quantitatively  correct.  In  these  latter,  it  may  be  sup- 
posed that  a  constitutional  peculiarity  of  the  digestive  function  of  the  infant 
plays  a  part,  for  innumerable  infants  thrive  on  unaltered  whole  milk  for  a 
long  time.  This  inherent  peculiarity  of  the  infant  is  further  demonstrated 
by  the  fact  that  the  symptom  group  is  often  encountered  in  infants  that  are 
receiving  as  high  as  five  per  cent,  of  carbohydrate  and  that  such  children 


Weight. 


Week. 


<£/)/) 

J. 

6. 

7. 

s. 

9. 

10. 

11. 

/£ 

ISflfi 

/ 

5WO 
WO 
KOO 
5100 
)000 
WOO 
4800 

4m 

MOO 

uoo 
woo 

4200 
MOO 
WOO 

/ 

/- 

/ 

f 

jj 

y 

/ 

/ 

/ 

I 

1 

A/ 

r1 

^f 

J 

r4 

P 

\\ 

J 

V 

/ 

I  ^ 

f 

J 

•V 

A 

n 

t 

/ 

/ 

V 

J 

Normal  child. 


Sick  child. 


Fio.  73. — Weight  curves  showing  the  increase  of  a  healthy  infant  as  compared  with  one 
suffering  with  dystrophy. 

often  develop  satisfactorily  if  the  starch  is  increased  to  as  high  as  ten  per 
cent.,  and  even  higher. 

Pathogenesis. — The  explanation  of  the  failure  of  development  in  spite 
of  food  of  sufficient  caloric  value  is  usually  sought  in  a  disturbance  of  the 
metabolism  of  some  one  constituent  of  the  milk.  Most  commonly,  the 
blame  has  been  laid  upon  the  fat  metabolism.  Recently  the  suggestion 
has  been  made  that  increased  putrefaction  in  the  intestine  might  possibly 
be  the  cause.  It  seems  more  probable,  however,  that  the  disturbance  of 
the  fat  metabolism  as  well  as  the  intestinal  putrefaction  is  secondary  to  the 
low  carbohydrate.  In  this  case,  the  condition  would  be  explained  as  a 
carbohydrate  requirement.  Such  a  condition  is  characteristic  of  rickitic 
infants,  of  those  with  spasmophilia  and  the  exudative  child. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  267 

Metabolism. — The  metabolism  is  apparently  not  greatly  altered  so  far 
as  the  absorption  of  organic  substances  is  concerned,  although  there  may 
be  some  slight  reduction  in  the  absorption  of  the  fats.  In  consequence  of 
altered  intestinal  conditions,  an  increased  secretion  of  alkalies  into  the  bowel 
occurs,  partly  in  combination  with  the  abnormal  quantities  of  higher  and 
lower  fatty  acids  and  partly  by  increased  secretory  activity.  The  balance  of 
the  earthy  alkalies  may  even  become  negative.  This,  however,  is  not  so 
important  in  the  matter  of  gain  in  weight  as  the  coincident  reduction  of  the 
sodium  and  potassium  retention.  The  reduction  of  the  available  quantity 
of  these  mineral  substances,  so  important  for  growth,  is  probably  the  cause 
of  the  decreased  development.  The  irregularities  of  absorption  and  reten- 
tion, due  to  the  variation  of  alkali  and  water  content,  are  the  basis  of  the 
variation  in  weight.  The  beneficial  action  of  increased  carbohydrate  is  ex- 
plained by  the  marked  affect  upon  the  alkali  reserve  and  the  water  retention. 

The  fat-soap  stools  are  distinguished  from  the  normal  by  the  difference 
in  the  partition  of  the  fecal  fat.  They  contain  much  more  of  the  earthy- 
alkali  soaps  and  much  less  of  the  free  fatty  acids.  Their  light  color  is 
caused  by  an  extensive  reduction  of  the  bilirubin  into  colorless  urobilinogen. 
A  strong  alkalin  reaction  in  the  large  intestine  is  necessary  for  the  formation 
of  such  stools. 

Soap  stools  were  at  first  looked  upon  as  pathologic,  i.e.,  as  evidence 
of  the  abnormally  great  excretion  of  bases  into  the  bowel.  It  is  certain  now 
that  these  materials  occur  regularly  in  the  feces  under  perfectly  normal 
digestion  if  the  alkalin  reaction  is  sufficiently  strong;  so  that  the  diagnosis 
of  nutritional  disturbance  cannot  be  made  from  the  soap  stools  alone.  Some 
feeding  cases  are  seen  which  fail  to  thrive  because  their  caloric  requirement 
of  about  100  calories  per  kilo  is  largely  supplied  by  milk.  The  history  and 
a  careful  examination  reveals  no  definite  pathology  and  there  is  no  diar- 
rhoea. Such  cases  may  be  included  under  the  group  of  dystrophy  due  to 
excessive  milk  feeding.  In  the  differential  diagnosis  the  group  of  dystro- 
phies due  to  inanition  and  also  the  failure  of  growth  due  to  constitutional 
anomalies  must  be  considered.  The  latter  is,  of  course,  still  a  purely  hypo- 
thetical condition  and  its  action  in  delaying  growth  is  far  from  being  under- 
stood. Such  an  endogenous  disturbance  of  growth  resists  all  therapeutic 
intervention.  Delayed  development  also  occurs  in  cases  where  there  is 
sufficient  carbohydrate  in  the  mixture.  This  is  probably  an  early  stage  of 
dyspepsia  in  which  the  characteristic  changes  in  the  stool  have  not 
taken  place. 

Prognosis. — The  prognosis  is  favorably  influenced  by  proper  regulation 
of  the  food  mixture. 

Treatment. — The  treatment  consists  in  a  rational  regulation  of  the 
quantity  of  food  and  the  number  of  meals,  in  a  reduction  of  milk  and  the 
addition  of  suitable  carbohydrates  to  the  diet.  In  disturbances  of  recent 
origin,  the  addition  of  gruel  or  flour,  with  a  slight  reduction  in  the  quantity 
of  milk,  frequently  produces  immediate  benefit.  The  following  list  of  carbo- 
hydrate foods  is  suggested  in  order  of  value.  Dextrin-maltose  preparations, 
(malt  soup,  etc.);  prepared  or  dextrinized  flours;  toasted  breads,  simple 


268  TEXT-BOOK  OF  PEDIATRICS 

flours.  Sugar  of  milk  is  to  be  excluded  and  cane-sugar  should  be  used  only 
in  combination  with  gruel  or  flour.  The  quantity  of  the  carbohydrate 
should  be  five  per  cent,  of  the  total  amount  of  food  given,  although  fre- 
quently one  needs  more.  The  sum  total  of  the  nourishment  should,  at  first, 
be  small;  when  the  tolerance  of  the  child  has  been  ascertained,  it  may  be  in- 
creased until  finally  the  child  itself  determines  the  quantity  which  will  it  take. 
Few  and,  at  most,  not  over  five  feedings  in  twenty-four  hours  are  to  be  given. 

If  the  carbohydrate  used  does  not  give  satisfactory  results,  one  of  higher 
value  is  to  be  substituted.  In  cases  of  long  standing,  it  is  well  to  give  the 
most  efficacious  form  from  the  beginning.  Liebig  's  malt  soup  may  be  used, 
according  to  the  formula  of  A.  Keller,  or  buttermilk  mixture. 

Malt  soup,  with  its  nutritive  value  of  about  700  calories  per  litre,  is 
sufficient  for  children  to  the  weight  of  5  kilos,  or  11  pounds,  and  to  the  age  of 
seven  or  eight  months.  In  older  and  heavier  children,  it  should  be  mixed  with 
more  milk,  less  water  and  less  flour;  otherwise  the  mixture  becomes  too  thick. 
Children  under  three  months  of  age  should  be  given  only  two-thirds  of  the 
original  solution  of  carbohydrate. 

Malt  soup  is  prepared  as  follows :  Stir  50  grams  (2  ounces) ,  of  white  flour 
into  one-third  of  a  litre  (11  ounces)  of  milk,  warming  it  gradually.  In 
another  dish  dissolve  100  grams  (3}/£  ounces)  of  malt  soup  extract  (malt 
extract  neutralized  with  potassium  carbonate),  in  two-thirds  of  a  litre  (22 
ounces)  of  water.  Mix  this  with  the  milk  and  flour;  boil  and  strain  through 
a  fine  sieve. 

Malt  soup  produces  somewhat  thin  and  frequent  stools  and  is  therefore 
to  be  recommended  when  constipation  follows  the  use  of  other  food. 

Buttermilk  intended  for  use  in  infant  feeding  should  be  produced  in  as 
cleanly  a  manner  as  possible.  Its  acidity  should  be  about  7  c.c.  normal 
NaOH  solution. 

Heat  one  quart  of  buttermilk.  Mix  five  grams  (^  ounce),  or  two  level 
tablespoonfuls  of  flour  to  a  smooth  paste  with  a  few  tablespoonfuls  of  the 
buttermilk.  Stir  the  paste  into  the  remainder  of  the  hot  buttermilk.  Con- 
tinue stirring  until  it  boils,  withdraw  from  the  fire  a  moment,  and  then 
reboil  without  stirring.  Add  50  to  70  grams  (l%-2%  ounces)  of  granu- 
lated sugar,  dissolving  it  thoroughly  and  bring  the  mixture  to  a  boil  the 
third  time. 

Changes  in  the  relative  quantities  may  be  made  to  meet  the  tendency  to 
either  constipation  or  diarrhoea.  The  dextrin-maltose  mixture  may  be 
substituted.  Benzosulphinidum  (saccharin),  may  be  used  if  the  sugar 
given  does  not  make  the  mixture  sweet  enough.  Beginning  with  two  to 
three  per  cent.,  the  quantity  may  be  increased  gradually. 

When  the  child  is  given  this  therapeutic  diet,  an  increase  in  weight 
should  immediately  follow  and  continue  progressively;  a  noticeable 
improvement  in  the  general  well-being  should  be  observed  (Fig.  74);  and 
the  stools  should  be  of  good  quality.  If  improvement  is  not  seen  and 
marked  diarrhoea  does  not  suggest  the  transition  to  the  type  of  dyspepsia, 
it  is  necessary  to  make  greater  changes  in  the  carbohydrate  components 
of  the  food  (see  next  division).  Malt  soup  or  buttermilk  having  been  given 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


269 


for  six  or  eight  weeks,  an  attempt  should  be  made  to  return  to  an  ordinary 
diet  and  to  ascertain  thereby  whether  a  longer  period  of  the  therapeutic 
diet  is  necessary.  The  recovery  may  be  considered  complete  when  con- 
tinued development  is  reestablished  upon  ordinary  milk  mixtures. 

The  therapeutic  dietaries  above  are  better  adapted  to  older  infants. 
In  new-born  infants  and  those  of  four  to  six  weeks,  great  care  must  be  exer- 
cised in  making  changes.  Gradually  increasing  amounts  of  gruels  and  sugars, 
preferably  dextrin  and  maltose  mixtures  and  granulated  sugar  up  to  seven 
per  cent.,  or  small  amounts  of  buttermilk  mixture  with  five  per  cent,  sugar, 
may  be  cautiously  employed.  If  immediate  improvement  is  not  noted, 


'height. 


Milk  and  Sugar. 


FIG.  74. — Typical  curve  of  successful  treatment  of  dystrophy  with  diet  poor  in  fat 
and  high  in  carbohydrate  (MS.  =Malt  Soup). 

there  is  danger  of  transition  to  dyspepsia  and  the  treatment  for  this  con- 
dition is  advisable  from  the  onset. 

2.  Dystrophy  as  a  result  of  excessive  flour  feeding.  .  (Flour-feeding* 
injury  of  Czerny  and  Keller.) 

Pap  or  flour  paste  feeding,  with  or  without  small  additions  of  milkor  other 
food  material,  is  a  method  of  infant  feeding  still  encountered  occasionally. 
Flour-feeding  injuries  may  also  be  caused  when  a  flour  diet,  ordered  by  the 
physician  or  selected  by  the  mother  herself  to  cure  a  diarrhoea,  is  continued 
for  too  long  a  time.  The  younger  the  child,  the  more  rapidly  does  injury 
occur  when  flour  is  the  chief  constituent  of  the  diet. 

Symptoms. — In  not  a  few  cases,  disease  symptoms  fail  to  appear  for 
some  time  in  spite  of  the  improper  diet.  A  normal  development  may  be 


270 


TEXT- BOOK  OF  PEDIATRICS 


simulated  for  a  time  for  the  great  water-retaining  power  of  the  carbohydrate 
causes  marked  increase  in  weight.  The  general  appearance  of  the  child  is 
good  and  the  fat  deposits  abundant.  But  even  at  this  time,  certain  abnor- 
malities may  be  observed.  The  musculature  may  be  slightly  hypertonic, 
the  complexion  poor;  a  nervous  irritability  (latent  tetany)  may  be  dem- 
onstrated upon  close  examination. 
Later,  the  development  of  extreme 
symptoms  is  threatened.  A  severe 
flour-feeding  injury  develops  which 
may  take  on  varyingly  graded  forms, 
according  to  the  exclusive  or  non-ex- 
clusive use  of  this  article  of  diet. 

The  atrophic  type  appears  when 
the  feeding  has  consisted  of  flour 
alone,  without  the  addition  of  salt. 
It  can  hardly  be  differentiated  from 
simple  severe  starvation.  The  only 
distinctive  features  are  the  hyperto- 
nicity  of  the  muscles  and  the  drying 
out  of  the  tissues,  which  are  partic- 
ularly noticeable.  A  brownish-red 
coloring  of  the  skin  should  attract  es- 
pecial attention. 

In  the  hydremic  form,  which  oc- 
curs in  flour  feeding  with  large  addi- 
tions of  salt,  the  weight  is  increased 
markedly,  in  consequence  of  the  re- 
tention of  large  quantities  of  water  in 
the  tissues.  This  may  be  recognized 
clinically  by  a  pale,  bloated  appear- 
ance of  the  face,  the  spongy  consist- 
ency of  the  skin  and,  finally,  by  the 
appearance  of  edema  without  evi- 
dences of  injury  to  the  kidneys 
(Fig.  75). 

A  hypertonic  form  is  also  described 
in  which  the  chief  symptom  is  the 
rigidity  of  the  musculature.  This 
hypertonicity  may  at  times  take  so 
severe  a  form  that  not  only  the  limbs 

but  the  entire  body  becomes  stiff.  This  condition,  however,  is  not  confined 
to  flour-feeding  injuries  alone,  but  may  occur  in  other  disturbances 
of  nutrition. 

Stools  are  formed  or  soft,  are  of  brown  or  yellow  color,  alkalin  or  acid, 
according  to  the  flour  used  and  to  the  tendency  to  constipation  or  diarrhoea. 
If  the  digestion  of  the  flour  is  impaired,  they  become  pasty,  slimy  and 
foamy,  due  to  the  formation  of  gas,  have  a  foul,  acid  odor,  and  contain 


FIG.  75. — Alimentary  edema.    (University  Chil- 
dren's Hospital,  Breslau,  Prof.  Tobler.) 


271 

many  undigested  particles  which  will  stain  with  iodin.  Irritation  of  the 
large  intestines,  with  symptoms  of  colitis,  may  result  from  the  fermentation 
of  the  flour. 

A  characteristic  peculiarity  of  flour-feeding  injury  is  the  great  and 
sudden  variation  of  the  weight-curve  which  occurs  spontaneously,  or  when 
the  child  is  attacked  by  an  additional  nutritive  disturbance,  or  by  an  infec- 
tion. Then  a  fall  of  several  hundred  grams,  or  even  a  kilogram,  may  occur 
within  a  few  days,  accompanied  by  correspondingly  severe  general  symp- 
toms. Such  events  are  the  more  frequent,  because  such  children  show  a 
definite  reduction  of  immunity  which  affords  an  especially  responsive  soil 
for  infective  organisms  which  produce  bacterial  injuries  of  the  most  variable 
sort ;  such  as,  pyodermia,  inflammatory  lung  affections,  and  pyelitis.  Of  the 
non-bacterial  complications,  cornea!  and  conjunctival  xerosis  may  be  men- 
tioned, while  manifest  tetany  (spasmophilia)  is  not  uncommon. 

Metabolism  and  Pathogenesis. — The  disturbance  of  the  organism 
occurring  in  exclusive  flour  feeding  is  to  be  considered  a  qualitative  inani- 
tion, produced  by  the  absence  of  one  or  more  of  the  necessary  tissue-building 
foods  (fat,  and  in  part,  also,  protein  and  salts);  on  account  of  which  the 
formation  of  normal  body  tissue,  if  not  the  development  in  general,  is  impos- 
sible. Usually  the  caloric  value  of  the  food  is  insufficient,  so  that  quanti- 
tative inanition  also  plays  some  part.  The  enormous  quantity  of  water 
retained,  because  of  the  large  salt  content  of  flour  food,  stands  in  direct 
relation  to  the  variations  of  weight.  The  reduction  of  immunity  may  be  due 
rather  to  the  scant  formation  of  antibodies,  as  a  consequence  of  inanition, 
than  to  the  high  water  content  of  the  body. 

Prognosis. — The  prognosis  depends  upon  the  age  of  the  child  and  the 
duration  of  the  period  of  incorrect  feeding.  The  younger  the  child  and  the 
longer  the  continuance  of  flour  feeding,  the  less  hopeful  is  the  final  result. 
The  great  mortality  is  caused  rather  by  unavoidable  intercurrent  infections, 
than  by  the  feeding  injury  itself.  The  tetany  and  the  spasmophilic  convul- 
sions resulting  from  it  are  very  dangerous  manifestations. 

Prophylaxis. — The  incidence  of  a  primary  flour-feeding  injury  is 
avoided  by  an  appropriate  diet.  It  is  important  to  consider,  the  possibility 
of  the  occurrence  of  such  an  injury  when  flour  feeding  is  resorted  to  for 
therapeutic  purposes,  whether  for  the  purpose  of  alleviating  symptoms  of 
spasmophilia  or  for  the  treatment  of  dyspeptic  diarrhoea.  The  danger  may 
be  avoided  in  the  first  instance  by  the  addition  of  casein  preparations,  fat 
and  small  amounts  of  salts,  and  in  the  second  case  by  continuing  the  pure 
flour  diet  for  only  a  very  few  days;  and  overcoming  the  difficulties  of  a  return 
to  a  milk  diet  by  the  methods  to  be  described  below. 

Treatment. — In  young  infants,  and  especially  in  the  severer  class  of 
cases,  the  most  rapid  recovery  is  to  be  expected  from  breast-milk  feeding. 
Remembering  that  inanition  may  have  caused  a  lowering  of  the  limits  of 
tolerance,  it  is  well  to  begin,  as  in  decomposition,  with  small  quantities 
200-300  c.c.  (7-10  ounces  per  diem) ;  and  then  to  increase  the  amount  as 
carefully  but  as  rapidly  as  possible.  Whole  milk,  slightly  diluted,  or  milk 
with  moderate  carbohydrate  additions  (3-5  per  cent.),  are  the  artificial 


272  TEXT-BOOK  OF  PEDIATRICS 

mixtures  to  be  recommended.  With  these  infants  it  is  well  to  begin  as 
though  decomposition  were  present.  Protein-milk  has  given  very  good  and 
certain  results. 

In  all  these  cases — in  so  far  as  we  do  not  have  to  deal  with  the  purely 
atrophic  type,  a  decided  loss  of  weight  is  to  be  expected  as  a  result  of  the 
feeding  of  mixtures  poor  in  carbohydrates,  because  of  the  rapid  loss  of  the 
water  which  has  been  retained  during  the  flour  feeding.  Occasionally  this 
may  produce  a  serious  condition  and  it  is  advantageous  therefore  to  retard 
the  loss  by  the  addition  of  small  amounts  of  flour  or  of  dextrin  and  maltose 
preparations  to  the  milk  mixture. 

If  the  change  from  flour  to  milk  mixtures  is  made  gradually  by  adding 
small  quantities  of  milk  to  the  gruel,  as  is  customary  when  the  period  of 
flour-soup  feeding  for  the  relief  of  diarrhrea  is  to  be  ended,  the  diarrhrea 
often  recurs;  which  leads  to  the  further  discontinuance  of  milk  in  the  mix- 
ture, and  to  the  conclusion  that  milk  is  not  well  borne  by  the  child.  Fre- 
quently this  trouble  is  due  to  the  fact  that  flour  ferments  more  readily  in 
the  presence  of  milk;  as,  for  example,  with  sugar,  a  strong  solution  of  which 
may  be  taken  care  of  in  dyspepsia,  while  the  same  amount,  added  to  milk, 
produces  symptoms  of  severe  intestinal  irritation.  In  these  cases,  the 
desired  results  are  often  obtained  if  the  change  is  made  suddenly  and  the 
flour  omitted  at  once.  In  this  event,  again,  the  best  results  are  obtained  by 
feeding  protein-milk. 

3.  Dystrophy  as  a  result  of  inanition. 

In  addition  to  the  forms  of  dystrophy  considered  above,  must  be  added 
the  innumerable  cases  in  which  the  failure  of  proper  development  is  due 
solely  to  quantitative  insufficiency  of  food.  A  common  cause  of  this  is  a 
food  of  too  great  dilution,  the  caloric  value  is  so  reduced  that  the  child 
cannot  take  enough  to  supply  its  requirement.  Frequent  vomiting  and 
regurgitation  is  a  cause.  Inanition  also  plays  an  important  role  in  those 
older  children  who  have  been  much  delayed  in  weight  but  are  still  being  fed 
on  the  caloric  requirement  of  that  weight  instead  of  the  requirement  of  a 
normal  child  of  that  age.  They  have  a  much  greater  requirement  than 
younger  infants  of  the  same  age  and  will  not  thrive  on  100  to  150  calories 
per  kilo.  At  times,  children  are  seen  who,  because  of  anorexia,  do  not  take 
sufficient  food  of  their  o\vn  accord  to  cover  their  needs. 

Diagnosis. — The  diagnosis  is  made  by  an  investigation  of  the  actual 
amounts  of  food  taken  and  the  determination  of  the  caloric  value  of  the  same, 
in  relation  to  the  age  and  weight. 

Treatment. — In  the  milder  cases,  gain  in  weight  and  improvement  in 
the  general  development  may  readily  be  obtained  by  changing  to  a  more 
concentrated  food  or,  if  necessary,  by  giving  seven  or  more  feedings  instead 
of  the  customary  five.  If  the  child  is  markedly  underweight  and  does  not 
take  its  food  well,  highly  concentrated  food  must  be  given.  In  such  a  case, 
whole  milk  with  twelve  to  seventen  per  cent,  of  carbohydrate,  which  nearly 
doubles  its  food  value ;  concentrated  protein-milk  with  fifteen  to  twenty  per 
cent,  carbohydrate;  Sauer's  farina  mixture;  and  other  thick  gruels  are 
valuable.  Fat  may  be  added  to  the  food  in  the  form  of  butter  or  cream. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  273 

These  are  the  cases  in  which  the  "butter-flour  mixture"  of  Czerny  and 
Kleinschmidt  is  especially  indicated  (see  feeding  of  normal  infants  in 
General  Part). 

B.  NUTRITIONAL  DISTURBANCES  WITHOUT  Toxic  MANIFESTATIONS 

WITH  DIARRHOEA. 

4.  Dystrophy  with  dyspepsia  (chronic  dyspepsia). 

Etiology. — In  many  cases,  the  cause  of  the  failure  of  development,  the 
dystrophic  condition,  is  found  in  abnormal  digestive  processes.  This  may 
occur  without  producing  extreme  gastro-intestinal  symptoms,  both  in  pri- 
marily healthy  children  and  in  conjunction  with  acute  dyspepsia  or  with 
flour  or  milk-feeding  dystrophy.  The  condition  is  encountered  when  there 
is  a  distinct  intestinal  digestive  insufficiency  for  the  food  offered.  It  may 
be  the  result  of  absolute  or  relative  inanition;  or  of  primary  reduction 
of  the  tolerance,  especially  by  infection.  This  insufficiency  may  become 
so  great  that  pathological  fermentation  takes  place  and  brings  on  the 
symptom-complex  to  be  described.  The  products  of  fermentation  cause  in- 
creased peristalsis  and  resulting  diarrhoea. 

Symptoms. — The  symptoms  of  disturbed  gastro-intestinal  function  are 
the  chief  indication  of  the  dyspeptic  condition.  The  appetite  may  be 
diminished;  regurgitation  and  vomiting  may  occur.  The  motor  power  of 
the  stomach  is  reduced.  The  analysis  of  the  stomach  content  usually  shows 
the  absence  of  free  HC1.  But  the  free  and  volatile  fatty  acids  are  increased, 
as  can  be  recognized  from  the  characteristic  odor.  Frequently  the  abdomen 
is  distended.  Increased  peristalsis  may  be  visible  or  may  be  determined  by 
auscultation.  There  is  a  tendency  to  flatulence  and  colic,  with  a  resultant 
restlessness  of  the  child.  The  stools  are  more  numerous  and  definitely 
abnormal.  They  become  thinner,  watery  or  lumpy  and  contain  mucus. 
Their  odor  is  abnormal,  indicating  either  putrefaction  or  fermentation. 
Their  chemical  reaction  is  variable,  usually  acid.  Their  color  is  often  green, 
in  consequence  of  the  oxidation  of  bilirubin  to  biliverdin. 

The  increased  peristalsis  interferes  more  or  less  with  the  absorption  of 
the  products  of  digestion,  a  fact  which  may  be  determined  not  only  by 
metabolism  experiments,  but  also  by  macroscopic,  microscopic  and  chemical 
examination  of  the  feces. 

The  stools  contain  fat  soaps,  seen  as  small  white  or  yellowish  lumps 
("milk  curds"),  from  which  fatty  acid  crystals  may  be  obtained  by  heating 
with  strong  mineral  acids.  Neutral  fats  in  the  form  of  fine  granules  or 
coarser  globules,  and  fatty  acids  in  the  form  of  needles,  clusters  or  droplets 
are  also  present.  Usually  present  in  small  amounts  only,  both  occur 
occasionally  in  enormous  quantities.  Microscopically,  fatty  stools  are 
soapy  or  shiny  in  appearance,  semisolid  or  fluid  in  form,  yellow  or  green  in 
color,  and  of  markedly  acid  reaction.  In  the  stained  preparation,  a  large 
number  of  Gram  positive  bacilli  are  noticeable,  resembling  in  this  respect, 
the  stools  of  the  breast-fed  infant. 

A  good  conception  of  the  distribution  of  the  fats  may  be  obtained  by 
staining  a  smear  with  dilute  carbol-fuchsin.  Neutral  fat  remains  unstained, 
soap-fat  appears  bright  pink  and  fatty  acid  bright  red.  The  fat  globules  in 
18 


274  TEXT-BOOK  OF  PEDIATRICS 

the  stools  vary  in  the  shade  of  red,  so  that  we  may  conclude  that  the  neu- 
tral fat  is  always  mixed  with  fatty  acids  (Fig.  76). 

Flour  stools  are  pasty  or  foamy.  With  iodin,  the  undigested  starches 
stain  blue  and  the  erythrodextrins  red.  Frequently,  large  numbers  of 
idiophilic  bacteria  may  be  found. 

For  a  long  tune,  the  question  whether  undigested  casein  appears  in  the 
stools  has  been  of  interest.  The  whitish-yellow  flakes,  or  so-called  "milk 
curds, "  have  been  erroneously  considered  as  particles  of  casein  which  had 
escaped  absorption  because  of  their  indigestibility.  It  is  now  an  estab- 
lished fact  that  these  alleged  casein  flakes  consist,  almost  entirely  of  the 
salts  of  fatty  acids  and  of  bacteria.  Only  under  raw-milk  feeding  do  large, 

tough,  rubber-like  casein  curds  pass 
undigested  through  the  intestine. 
Their  appearance  does  not  permit 
us  any  conclusion  as  to  their  path- 
ogenetic  importance. 

The  general  symptoms — when 
sharply  differentiated  from  other 
severe  forms  of  disturbance  of  nutri- 
tion, e.  g.,  intoxication,  decompo- 
sition, with  acute  incidence — are 
not  of  great  variety.  The  patient 
is  pale  and  restless,  his  sleep  light 
and  his  disposition  altered.  The 
tone  of  the  tissues  is  reduced.  While 
the  body-weight  may  increase  in 

^^  the  milder  cases,  there  is  usually 

» .      Y  *  no  increase  or  a  slight  loss  of  weight. 

•      *•  •*_»/  The   body-temperature   is  impor- 

tant; the  daily  curve  varying  be- 
tween a  slightly  subnormal  point 
and  slight  fever,  (see  alimen- 

FIG.  76. — Microscopic  preparation  of  stool  in  case       *™Ty  iGVGT). 
of  fat  diarrhoea.    Stained  with  carbol-fuchsin.    Fatty  T>a  timer  An  acic        fQoa  o1c./~>  mvnamT 

acids  red,  soap  fats  pink.  .rainogenesis.     ^Qee  aiso  general 

pathogenesis.)  The  local  symptoms 

of  dyspepsia  are  usually  caused  by  the  increased  formation  of  the  acids  of 
fermentation.2  In  all  probability,  the  pathologic  decomposition  of  the 
carbohydrates  (sugar,  flour),  must  be  considered  the  primary  cause  of  the 
fermentation;  while  the  decomposition  of  the  fat,  when  given  in  ordinarily 
small  amounts,  is  secondary  to  it.  No  satisfactory  proofs  of  injury  to  the 
intestinal  tract  by  the  decomposed  digestive  products  of  casein,  of  which  so 
muchhasbeenwritten,havebeenbroughtforward.  Rather,has  it  been  shown 
that  the  harmful  decomposition  of  carbohydrates  may  be  combated  by  large 

2  Cases  are  occasionally  seen  in  which  there  is  a  poor  gain  in  weight  with  increased 
slimy  stools,  and  which  are  easily  cured  by  the  addition  of  a  more  readily  assimilated 
carbohydrate.  Evidently,  there  is  an  actual  carbohydrate  hunger  in  this  condition. 
The  chemistry  is  not  understood. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  275 

quantities  of  casein  which  acts  beneficially  as  a  therapeutic  agent.  It  is 
true  that  when  large  amounts  of  casein  are  fed,  there  is  a  possibility  of 
the  protein  entering  into  the  circulation  with  severe  general  symptoms,  as 
frequently  happens  in  premature  and  very  weak  infants.  The  main  sup- 
port of  the  view  that  the  primary  cause  of  dyspepsia  is  the  carbohydrate,  lies 
in  the  fact  that  it  is  nearly  always  possible  to  reduce  the  abnormal  fermenta- 
tion and  the  excessive  peristalsis  by  sharp  reduction  of  the  sugars,  eliminat- 
ing, in  certain  cases,  even  the  lactose  of  the  milk  itself.  The  different  sugars 
show  important  differences  in  their  susceptibility  to  fermentation.  Sugar  of 
milk  is  most  readily  fermented;  cane-sugar  less  readily;  while  the  dextrin 
and  maltose  preparations  of  commerce,  dextri-maltose,  etc.,  are  the  least 
liable  to  fermentation. 

The  results  of  clinical  experiment  indicate  that  the  intestinal  tolerance 
for  carbohydrate  and  the  greater  or  less  tendency  to  pathologic  fermentation 
are  not  constant,  but  are  dependent,  as  is  the  tolerance  for  fat,  upon  the 
liquid  in  which  the  carbohydrate,  in  solution  or  suspension,  is  given.  A 
given  quantity  of  sugar  in  undiluted  whey  gives  rise  to  symptoms  of  dys- 
pepsia more  readily  than  when  added  to  water  or  diluted  whey.  Thus  an 
increase  of  the  protein  content  may  counteract  the  tendency  to  fermen- 
tation, while  an  increase  of  the  whey  with  reduced  protein  favors  it. 

The  pathogenesis  of  the  general  symptoms  of  dyspepsia  is  akin  to  that  of 
the  symptoms  common  to  the  several  grades  of  disturbance  of  nutrition. 

A  reduction  of  absorptive  power,  which  may  be  demonstrated  clinically, 
has  been  proved  by  metabolism  experiments.  Not  only  the  organic,  but  the 
inorganic  food-stuffs  are  involved  in  this  reduction.  However,  in  dyspepsia, 
in  contrast  to  decomposition,  a  lessening  of  the  mineral  bases  of  the  body  is 
rare,  because  increased  retention  of  the  inorganic  salts  compensates  for  the 
diminished  intake.  So  rapid  a  deterioration  and  so  greatly  reduced  tone  of 
the  tissues  is  not  seen,  therefore,  in  dyspepsia. 

Variations  in  the  Course. — It  is  essential  in  every  case  to  attempt  to 
arrive  at  some  conclusion  as  to  the  etiologic  characteristics.  This  is  espe- 
cially true  in  those  cases  in  which  the  dyspepsia  is  more  or  less  directly  the 
result  of  infection.  In  young  infants,  enteral  and  parenteral  infections  are 
very  commonly  seen  in  combination  with  secondary  disturbance  of  nutri- 
tion and  conversely  a  nutritional  disturbance  may  often  have  a  secondary 
infection  added  to  it.  There  can  be  no  doubt  of  the  presence  of  an  infective 
process  when  rises  in  temperature  persist  in  spite  of  the  correction  of  the  food 
as  required  for  the  dyspepsia.  Further  infection  must  be  suspected  when,  in 
spite  of  a  diet  practically  free  from  sugar  and  definitely  non-fermentation 
producing,  the  frequent  stools  still  contain  large  amounts  of  mucous.  Such 
a  condition  is  due  to  a  mild  secondary  enterocolitis.  The  pedantic  differ- 
entiation between  infection  and  dyspepsia  is  in  itself  of  minor  importance, 
provided  that  the  treatment  is  not  influenced  to  the  extent  of  deviating 
from  that  to  be  indicated  for  dyspepsia  in  the  following.  There  is  danger, 
however,  that  the  persisting  intestinal  irritation  kept  up  by  the  local  or 
hematogenous  infection  be  interpreted  as  a  continuance  of  the  fermentative 
process  that  initiated  the  disorder.  In  a  similar  manner,  the  dyspeptic 


276  TEXT-BOOK  OF  PEDIATRICS 

symptoms  that  appear  with  hunger  and  inanition  may  lead  the  treatment 
astray.  For  this  reason,  the  possibility  of  hunger  dyspepsia  should  con- 
stantly be  kept  in  mind.  This  especially  in  the  new-born. 

Diagnosis. — Diagnostically  it  is  important  to  determine  whether  the 
diarrhosa  is  merely  a  manifestation  added  to  simple  failure  of  development 
(dystrophy),  or  whether  it  is  a  far-reaching  nutritional  disturbance  with 
actual  loss  of  body  substance  (decomposition).  These  two  conditions 
differ  not  only  in  their  prognosis,  but  require  entirely  different  treatment. 
The  differentiation  is  made  from  the  clinical  examination  and  from  the 
history.  Emaciation,  sudden  losses  of  weight  and  subnormal  temperature 
indicate  decomposition.  A  history  of  repeated  diarrhoea  with  periods  of 
loss  of  weight,  and  recurring  injuries  reducing  the  tolerance  also  indi- 
cates a  reduction  of  the  functional  ability  of  the  organism  in  the  sense  of 
a  decomposition. 

Prognosis. — The  outcome  of  a  persisting  dyspepsia  may  still  be  favor- 
able, as  long  as  there  is  no  loss  of  weight  and  the  general  condition  of  the 
child  is  not  markedly  affected.  In  recurring  dyspepsia,  the  prognosis  must 
be  more  guarded  because  of  the  great  reduction  of  the  tolerance.  This  is 
also  true  in  cases  of  diarrhoea  in  infants  during  the  first  few  days  of 
life.  On  account  of  the  very  low  tolerance  at  this  age  and  the  readiness 
with  which  the  condition  may  go  on  to  decomposition  the  prognosis  is  al- 
ways grave. 

Dietetic  Treatment. — The  safest  food  for  cases  of  the  dyspeptic  form  of 
dystrophy  is  breast-milk.  Especially  during  the  first  few  weeks  of  life,  every 
effort  must  be  made  to  give  the  infant  the  natural  food,  for  at  so  early  an 
age  the  results  of  artificial  food  are  always  doubtful.  The  full  caloric  re- 
quirement may  be  supplied  in  breast-milk  but  even  with  this  food  it  is  well 
to  underfeed  slightly  at  first. 

In  using  artificial  food  in  the  treatment  of  dyspepsia,  the  cure  must  be 
affected  by  changes  in  the  composition  of  the  mixture  and  not  by  reducing 
the  quantity.  The  diarrhoea  may  be  stopped  temporarily  by  cutting  down 
the  diet  that  caused  it,  to  a  starvation  ration,  but  the  intestinal  fermenta- 
tion flares  up  again  as  soon  as  the  food  is  brought  up  to  the  requirement. 
The  course  to  be  chosen,  therefore,  is  rather  to  change  to  a  mixture  contain- 
ing less  fermentable  carbohydrate.  The  reduction  of  the  abnormal  fermen- 
tation is  most  rapidly  accomplished  (1)  by  the  reduction  of  a  possible  excess 
of  carbohydrate;  (2)  by  replacing  the  more  easily  fermented  sugar  of  milk  or 
cane-sugar  with  the  readily  assimilated  dextrinized  flours  or  maltose  and 
dextrin  mixtures;  (3)  by  the  addition  of  calcium  caseinate  (protolac, 
larosan)  up  to  two  per  cent. 

In  the  milder  cases,  these  additions  may  be  made  to  mixtures  of  gruels 
and  lean  milk  (Fig.  77).  When  the  symptoms  have  persisted  for  a  time,  it 
is  well  to  eliminate  even  the  lactose  of  the  milk  by  substituting  buttermilk. 
Some  authors  ascribe  a  beneficial  effect  to  the  acid  of  the  buttermilk. 

The  results  of  the  treatment  are  evidenced  by  the  reduction  of  the 
number  of  the  stools  and  the  improvement  of  their  consistency.  With  the 
slowing  up  of  the  peristalsis,  the  weight  as  a  rule  begins  to  increase.  The 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


277 


temperature,  which  during  the  illness  is  extremely  variable,  returns  to  the 
typical  monothermia.  Nevertheless,  it  usually  takes  weeks  before  the  gen- 
eral condition  of  the  infant  returns  to  the  normal  well-being. 

With  quite  a  few  children,  however,  this  method  fails.  While  the  loss 
of  weight  may  be  favorably  in- 
fluenced, the  stools  do  not  de- 
crease in  number  or  improve  in 
consistency;  or  the  loss  of  weight 
is  continued  and  the  diarrhoea 
persists.  In  these  cases,  we  have 
probably  to  deal  with  a  secon- 
dary infection  or  with  a  severe 
nutritional  disturbance  of  a  type 
transitional  to  decomposition. 
Nothing  can  be  more  mistaken 
or  more  disastrous  than  to  con- 
tinue underfeeding  with  the  idea 
that  the  intestine  will  yet  re- 
cuperate with  continued  rest. 
Children  are  killed  in  this  way. 
Only  a  quick  recourse  to  the 
treatment  indicated  in  infective 
nutritional  disturbances  and  in 
decomposition  will  avail.  There- 
fore we  would  urge  that  while 
the  schematic  rules  for  the  treat- 
ment of  dyspepsia  be  first  fol- 
lowed, under  no  circumstances 
should  the  underfeeding  be  con- 
tinued in  case  of  failure,  but 
that  the  directions  given  for  the 
treatment  of  decomposition  be 
instituted  at  once. 

One  of  the  most  successful 
methods  of  treating  dyspepsia, 
in  artificially-fed  children,  has 
been  the  use  of  protein-milk. 
While  this  is  not  necessary  in 
many  cases,  the  mixture  protects 
those  patients  who  do  not  re- 
spond to  the  ordinary  therapy 
from  the  delay  of  improvement  and  the  consequent  serious  loss  of  strength. 

In  the  treatment  of  chronic  forms  of  dyspepsia,  there  is  no  indication  for 
underfeeding.  Since  we  do  not  have  to  deal  with  a  temporary  injury,  but 
with  a  chronic  reduction  of  the  limits  of  tolerance,  the  added  trauma  of 
hunger  can  only  do  harm.  The  feeding  should  be  rational;  the  carbo- 
hydrates should  be  reduced  to  the  absolute  minimum  (from  2-3  per  cent.) 


I 

D 

ffl 

IV 

V 

3700 

// 

3600 

A/ 

/ 

3500 

A 

-A1- 

yV 

3400 

72 

v^ 

vy 

38.0 

37,0 

v\A, 

ts~J 

\/*N 

A>\A 

^L    A 

«*»/       V 

V 

V 

»"V/VV    V 

V* 

700 

600 

rJ 

M 

500 

400 

300 

V4 

+ 

i%    , 

200 

1,0 

) 

100 

0 

X 
III   1  XIX 
1  XXIX 
1  XXXX 
X     XX 

X 
XX  IX  XXX 

xxxxxxx 

XX    XX      1 
X 

1 

XXI   1       1  1 
XXXI    1      1 
XXX 

1  1  1  1  1  1 
III    1 

jl.L 

Fia.  77. — Dystrophy  with  dyspepsia  in  a  young  infant. 
Recovery  after  the  addition  of  casein  to  the  food. 


278  TEXT-BOOK  OF  PEDIATRICS 

at  once,  and  those  forms  more  difficult  of  assimilation  should  be  replaced  by 
the  more  readily  assimilated  dextrin  and  maltose  preparations.  If  this 
does  not  suffice  to  improve  the  condition  of  the  stools,  better  results  may 
be  obtained  with  breast-milk  or  protein-milk.  If  these  cannot  be  obtained, 
nothing  remains  but  to  continue  the  use  of  carefully  measured  quantities  of 
the  above  food  in  order  to  keep  the  child  alive  in  the  hope  that  increasing 
age  will  produce  an  increase  of  tolerance  and  resultant  recovery. 

Medication  is  usually  unnecessary.  Astringents  (tannigen,  tannalbin, 
tannocol,  etc.,  5  to  10  grains  four  to  five  times  daily;  or  bismuth  salicylate, 
five  grains  four  times  daily) ,  may  be  of  use  in  long  continued  irritative  cases 
with  mucoid  diarrhoea. 

II.  DECOMPOSITION3 
(PEDATROPHY) 

The  various  degrees  of  nutritional  disturbances  discussed  above,  while 
serious  do  not  have  actual  injurious  effect  upon  the  body  structure.  In  the 
next  grade,  decomposition,  however,  there  is  such  an  effect  with  a  true  loss 
of  body  constituents.  As  a  result  of  an  extensive  lesion  of  the  intestine, 
there  is  a  gradually  increasing  disturbance  of  the  metabolism.  This  leads  to 
destruction  of  body  substance  with  grave  pathologic  loss  of  body  fluids  and 
body  substance. 

Symptoms. — Dystrophy  is  in  the  stage  of  transition  into  decomposition 
when  marked  losses  of  weight  occur.  These  losses  are,  at  first,  gradual  but 
later,  and  in  severe  cases,  are  sudden  and  large.  As  the  case  progresses,  we 
may  have  extreme  emaciation  which  causes  the  "old  man"  appearance 
and  later  the  skeleton  like  body  of  the  "atrophic  infant"  (Figs.  78  and  79). 
The  abdomen  is  usually  distended,  even  tense;  the  musculature  flabby  or 
hypertonic.  The  patient  may  be  pale  at  first,  but  later  has  a  characteristic 
pasty  gray  color,  while  the  mucous  membranes  of  the  seemingly  huge  mouth 
are  a  deep  red. 

The  urine  is  free  from  protein  and  sugar.  The  stools  are  usually  dys- 
peptic, frequently  diarrhceic;  liquid  and  solid  evacuations  may  alternate. 
At  times,  during  periods  of  remission  of  the  fundamental  disease  process, 
only  formed  stools  are  passed.  In  a  peculiar  condition  known  as  fatty 
diarrhoea,  the  discharges  are  characterized  by  excess  of  fat.  Often  the 
stools  are  tarry  or  reddish  black,  due  to  bleeding  from  peptic  duodenal 
ulcers  (Fig.  80). 

At  first,  the  patients  are  irritable,  cry  a  great  deal  and  eat  ravenously. 
Later,  they  become  dull  and  lethargic.  There  is  a  noticeable  tendency  to 
slowing  and  irregularities  of  the  pulse.  The  temperature  may  be  subnormal 

3  " Decomponere "  means  to  "separate  into  its  constituents"  as  well  as  to  "change 
the  composition,"  (in  an  unfavorable  sense).  Both  definitions  apply  to  the  condition  in 
question.  Not  only  do  the  tissues  of  the  body  break  down,  while  their  separate  cell  con- 
stituents are  excreted  in  various  ways,  but  the  remaining  cell  contents  are  changed  in 
composition,  as  shown  in  their  seriously  disordered  functions.  Although  the  term 
decomposition,  and  particularly  alimentary  decomposition,  since  it  is  traceable  to  the 
influence  of  feeding,  has  been  criticised,  the  nature  of  the  condition  is  better  so  described 
than  by  the  ambiguous  word  "atrophy. " 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  279 

and  is  liable  to  great  variation  in  distinction  to  the  normal  monothermia. 
Edema  and  cyanosis  are  common  symptoms. 

Aside  from  the  emaciation  and  its  accompanying  phenomena,  decompo- 
sition is  characterized,  symptomatically,  by  the  sensitiveness  of  the  patient, 
or  rather  by  the  sensitivity  and  severity  of  his  paradoxical  reactions  to 
nutritive,  infective,  and  other  influences.  A  slight  alteration  in  the  quantity 
and  quality  of  the  nourishment  may  immediately  cause  a  very  threatening 
aggravation:  a  minor  bacterial  infection,  a  coryza,  a  bronchitis,  etc.,  may 
lead  to  serious  decline.  A  little  overheating  may  produce  high  fever  and 
collapse.  By  this  very  sensitiveness  the  diagnosis  of  the  condition  may  be 
rnade  when  the  child  is  in  a  remission,  or  is  beginning  to  recover  and  even 
when  the  symptoms  of  the  body  loss  are  not  apparent.  The  reduced  im- 
munity predisposes  to  infective  complications  (furunculosis  and  other  pyo- 


\ 

FIG.  78. — Facies  in  moderate  decomposition.     (Berlin  Children's  Asylum,  Dr.  Dessauer.) 

dermatites,  pyelitis,  septic  diseases,  bronchitis,  pneumonia,  etc.),  which 
occur  frequently  and  run  an  exceptionally  severe  course. 

A  peculiar  form  of  interruption  of  the  course  is  often  seen  in  decompo- 
sition and  also  at  times  in  dyspepsia.  To  this  the  name  of  "Reversion" 
has  been  applied.  The  patient  seems  to  be  doing  especially  well  for  several 
days.  There  is  a  constant  gain  in  weight  up  to  several  hundred  grams  and 
the  attendant  is  greatly  encouraged.  This  is  not  a  true  manifestation  of 
growth,  but  is  largely  due  to  a  retention  of  water.  The  slightest  error  in  the 
treatment  or  the  mildest  external  injury  throws  the  patient  back  and  the 
gain  is  lost  in  a  few  days.  The  patient  has  not  gained  anything  by  the  period 
of  improvement  but  has  actually  been  weakened. 

Pathogenesis  and  Metabolism. — Formerly  it  was  believed  that  inani- 
tion was  the  cause  of  severe  "atrophy"  and  was  due  to  interference  with 
food  absorption  in  consequence  of  a  chronic  inflammation  and  destruction 
of  the  secretory  mechanism.  The  foundations  of  this  teaching  are  today, 
however,  overthrown;  for  the  concurrent  reports  of  all  observers  show  that 
the  intestine  of  the  atrophic  child  is  anatomically  normal.  It  is  clearly  a 


280 


TEXT-BOOK  OF  PEDIATRICS 


question  of  a  functional  disturbance,  leading  to  a  reversive  metabolism, 
recognized  by  Parrot  many  decades  ago.  In  fact,  clinical  observations 
prove  that  we  have  to  deal  with  a  paradoxical  reaction  of  the  food  material; 
the  more  food  we  give  the  more  the  patient  loses,  while  in  the  milder  cases 
an  arrest  of  the  disease  may  be  secured  by  reducing  the  allowance  of  food. 
In  severe  cases,  of  course,  even  this  measure  will  not  stop  the  wasting. 
From  the  rapid  loss  of  weight,  it  will  be  seen  that  the  pathologic  loss  of 

water  and  salts  is  primary,  because  this 
alone  can  produce  such  sudden  changes 
in  weight,  while  other  tissue  losses  must 
be  more  gradual. 

The  experiments  in  metabolism 
have  cast  some  light  upon  this  problem. 
It  may  be  readily  understood  that  the 
continual  enteral  fermentation  grad- 
ually ,  produces  so  high  a  degree  of 
alteration  in  the  processes  of  digestion 
that  severe  damage  is  done  to  the 
agencies  of  interchange  between  the 
intestinal  content  and  the  tissues.  A 
radical  alteration  in  the  water  and  salt 
retaining  function  of  the  cells  probably 
ensues.  This  results  in  the  increased 
secretion  of  water  and  alkali  into  the 
intestine,  which  is  not  balanced  by  a 
compensatory  reduction  of  the  renal 
output  as  it  is  in  the  healthy  or  the 
only  slightly-ill  child,  in  whom  a  nega- 
tive balance  often  exists.  Doubtless 
abnormally  increased  quantities  of 
water  are  given  off  by  the  lungs.  As 
a  result  of  the  loss  of  salts  by  the 
bowel,  a  greatly  increased  excretion  of 
ammonia  in  the  urine  follows,  a  con- 
dition of  relative  acidosis.  The  alkalies 
are  lost,  in  part  by  increased  secretion, 
and  are,  in  part,  consumed  in  the 
necessary  neutralization  of  the  great  quantity  of  acids  formed  by  fermen- 
tation. To  cover  these  losses,  the  storage  depots  of  the  body  are  drawn 
upon.  When  these  are  exhausted,  those  stored  in  the  constant  constituents 
of  the  organism  must  provide  the  necessary  quantity  of  water  and  salts 
by  the  decomposition  of  the  cell  substances.  In  addition  to  this,  an  actual 
inanition  also  ensues.  The  carbohydrates  and  fats  are  fermented  in  large 
quantities;  the  acids  of  fermentation  prevent  the  normal  splitting  of  the 
sugar  preparatory  to  absorption;  and  as  a  result  of  the  violent  peristalsis 
large  quantities  of  food  material  pass  through  the  intestine  entirely  un- 
changed. To  this  is  often  added  the  semi-starvation  of  underfeeding 


FIG.  79. — Extreme  form  of  decomposition. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  281 

usually  adopted  for  therapeutic  purposes.  The  "decomposition"  of  the 
more  important  organs  finally  leads  to  so  great  an  alteration  of  their  cell 
conditions  and,  in  consequence,  of  their  functional  activities,  that  not  only 
because  of  the  continued  diarrhoea,  but  even  after  this  has  disappeared, 
the  normal  internal  metabolism  can  no  longer  be  maintained  and  an  auto- 
intoxication results  which  produces  the  terminal  symptoms  of  the  disease. 

Cases  of  decomposition  of  purely  alimentary  origin  are  probably  found 
in  new-born  and  very  young  infants  only.  In  older  children  the  infectious 
influence  takes  a  very  prominent  place  in  the  etiology.  To  this  must  be 
added  the  frequent  starvation  periods  employed  in 'the  attempt  to  stop  the 
diarrhoea,  which  undermine  the  strength  of  the  patient  more  and  more. 
Such  starvation  cause  recurrences  even  in  cases  on  the  road  to  recovery  and 
are  often  to  be  blamed  for  the  fatal  termination.  In  fact,  numerous  factors 
are  combined  in  the  pathogenesis  of  decomposition. 

Course. — In  young  infants  the  course  is  often  uninterrupted,  the  fatal 
outcome  occurring  in  a  few  days  or  weeks,  at  the  most.  In  older  children, 


FIG.  80. — Duodenal  ulcer  in  decomoosition.     Fatal  hemorrhage  occurred  from  this  lesion 
(Berlin  Children's  Asylum). 

periods  of  improvement  and  periods  of  decline  alternate.  Serious  catas- 
trophies  may  occur  anywhere  along  the  course.  In  this  manner,  we  may 
have  an  illness  of  weeks'  duration,  with  exacerbations  and  ameliorations. 
The  intestinal  processes  determine  the  occurrence  of  such  remissions.  As 
long  as  the  stools  are  infrequent  and  formed,  the  weight  remains  stationary 
or  there  may  even  be  slight  gains.  As  soon  as  diarrhoea  again  appears, 
there  is  actual  loss  of  body  substance.  A  sudden  change  in  the  disease- 
picture  is  often  brought  about  by  hemorrhage  from  the  peptic  duodenal 
ulcers,  which  are  generally  fatal.  The  etiology  of  these  ulcers  is  not  known. 
The  termination  of  unfavorable  cases  is  attended  by  a  variety  of  symp- 
toms. In  many  children,  a  narcosis  develops  with  an  absence  of  reflexes, 
general  torpidity — 'and  subnormal  temperature  continuing  for  a  number  of 
days.  Others  die  with  the  appearance  of  symptoms  which,  with  or  without 
fever,  resemble  those  of  alimentary  intoxication.  Sudden  death  in  collapse, 
in  consequence  of  some  exciting  influence  or  after  several  hours  of  hunger,  may 
occur.  Complicating  infections  tend  materially  to  increase  the  death-rate. 


282  TEXT-BOOK  OF  PEDIATRICS 

The  prognosis  depends  to  a  very  great  extent  upon  the  dietetic  treatment. 
If  errors  are  avoided  and  the  treatment  is  instituted  early  enough,  even  the 
extreme  cases  may  be  saved.  If,  however,  the  loss  of  weight  exceeds  one- 
third  of  the  original  body- weight  (the  so-called,  Quest 's  quotient) ,  recovery 
is  apparently  impossible. 

Diagnosis. — The  diagnosis  of  severe  cases  is  clearly  given  by  the 
clinical  picture.  The  mistake  of  confusing  the  symptomatic  emaciation  of 
tuberculosis  and  other  diseases  leading  to  cachexia,  or  the  weight-loss  of 
severe  starvation,  must  be  avoided  by  careful  examination  and  a  study  of 
the  history.  In  milder  forms,  the  differentiation  from  dystrophy  and  simple 
dyspepsia,  without  destructive  losses,  is  of  so  much  greater  importance  since 
the  treatment  indicated  for  these  conditions,  viz;  a  diet  rich  in  carbohydrates 
and  a  period  of  starvation,  may  cause  serious  injury  in  children  suffering 
with  decomposition.  In  such  cases,  the  history  is  of  the  greatest  impor- 
tance. Repeated  diarrhoea,  loss  of  weight,  in  contrast  to  the  stationary 
weight  incident  to  non-development  in  dystrophy,  or  in  infective  fever  of 
varying  degree,  are  suggestive  evidences  of  decomposition.  A  final  con- 
clusion must  be  reached  by  the  reaction  of  the  patient  to  the  prescribed  diet. 
If  with  a  fairly  plentiful  diet,  the  paradoxical  reaction  (diarrhoea,  loss  of 
weight,  occasional  fever,  etc.),  occurs  definitely  and  severely,  the  diagnosis 
of  decomposition  is  certain. 

Treatment. — -For  the  cure  of  decomposition,  it  is  necessary  that  the 
fermentation  which  causes  a  continuance  of  the  destructive  phenomena  be 
abated,  so  that  the  organism  may  again  retain  water  and  salts,  and  the 
digestion  may  again  take  care  of  the  organic  food-stuffs,  in  a  normal  manner. 
Therefore,  the  same  problem  is  present  as  in  dyspepsia  and  one  might  be 
inclined  to  inaugurate  the  same  treatment  as  it  demands;  that  is,  a  period 
of  starvation,  followed  by  a  gradually  increasing  use  of  suitable  food  mix- 
tures. In  fact,  this  procedure  is  frequently  adopted.  One  must  realize,  how- 
ever, that  success  cannot  rightly  be  expected,  save  in  a  certain  number, 
only,  of  older  infants;  and  among  these  only  in  cases  where  the  debility 
has  not  advanced  too  far.  For  the  methods  recommended  in  dys- 
trophy are  absolutely  contraindicated  by  the  principles  of  treatment  in 
any  severe  form  of  decomposition.  These  principles  are  (1)  that  the  child 
with  decomposition  must  not  be  starved;  (2)  that  the  child  should  be  put  to 
the  breast,  for  it  is  to  be  feared  that  artificial  feeding,  under  prevailing 
methods,  will  rapidly  and  progressively  aggravate  the  disease. 

In  children  with  severe  disturbances  of  nutrition,  the'dangers  of  a  star- 
vation period  are  very  much  greater  than  in  well  infants  or  those  with 
slight  disturbances.  Hunger  causes  much  more  rapid  loss  of  weight,  marked 
slowing  of  the  pulse,  subnormal  temperature  and  collapse  and  occasionally 
death.  Repeated  starvation  periods  at  short  intervals  are  especially 
dangerous.  The  second  or  third  such  period  is  usually  fatal  (Fig.  81).  The 
special  emphasis  laid  upon  this  point  is  necessary  because  starvation  treat- 
ment is  still  very  much  in  vogue  and  is  recommended  in  text-books.  Aside 
from  the  above,  it  is  further  true  that  subjecting  the  patient  suffering  from 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


283 


decomposition  to  hunger  periods  can  only  result  in  a  further  loss  of  strength. 
Persistent  underfeeding  makes  the  prognosis  very  grave  even  in  cases  in 

Weight.  Week. 


3600 


3300 


3100 
0000 


Stool 


2600 


m 


WO 
300 


100 
0 


19. 


u 


20. 


%M. 


21. 


\i\ 


ut: 


I  I  I   I+++     it     +     +4i«. 


FIG.  81 . — Showing  the  injury  caused  by  repeated  starvation  periods  in  cases  of  disturbance  of  nutrition. 
After  the  first  starvation  period  the  weight  is  stationary  for  a  time  but  there  is  no  improvement  of  the 
intestinal  condition.  Soon  the  temperature  rises  again  and  further  losses  of  weight  occur.  Death  resulted 
on  the  third  day  of  the  second  starvation  period. 

which  there  was  some  hope  of  recovery.  It  is  essential  that  the  calorie 
requirement  be  supplied  from  the  very  beginning  of  the  treatment.  In  the 
large  majority  of  the  cases,  this  is  not  possible  with  the  customary  artificial 


284  TEXT-BOOK  OF  PEDIATRICS 

foods  and,  for  this  reason,  breast-milk  is  to  be  preferred  to  all  other  forms 
of  food. 

In  the  use  of  breast-milk,  certain  points  must  be  taken  into  consideration; 
and  first,  the  matter  of  dosage.  The  curative  influence  of  breast-milk, 
apparently  due  to  the  constituents  of  the  whey,  is  not  at  first  so  active  as  to 
preclude  the  injurious  effect  due  to  the  fermentation  of  its  large  amounts  of 
sugar  and  fat.  This  danger  is  increased  as  more  food  is  taken;  yet  if  too 
little  is  given,  the  danger  of  renewed  injury  from  inanition  again  confronts 
us.  The  best  plan  is  to  give  a  daily  total  of  200-300  c.c.  (7-10  ounces)  without 
any  preceding  starvation  period.  It  is  better  to  give  the  breast-milk  from  a 
bottle  so  as  to  relieve  the  weakened  child  of  the  labor  of  sucking.  In  addi- 
tion to  the  food,  large  quantities  of  water  sweetened  with  benzosulphinidum 
(saccharin)  should  be  given.  Eight  to  ten  feedings  may  be  offered  in 
twenty-four  hours,  for  experience  has  shown  that  the  same  quantity  in  small 
doses  is  less  liable  to  cause  injury  than  in  large  ones.  In  the  shortest 
possible  time,  about  every  other  day,  the  quantity  should  be  increased 
until  by  the  seventh  to  the  tenth  day  100  calories  (130-150  c.c.),  per  kilo  of 
body-weight  are  being  given  and  in  less  frequent  feedings.  By  this  time,  the 
child  may  be  put  directly  to  the  breast. 

It  is  further  to  be  remembered  that  even  with  breast-milk  the  severer 
type  of  cases  will,  at  first,  show  an  aggravation  of  symptoms;  the  patient 
becomes  more  pale  and  more  dull;  a  subnormal  temperature  and  a  slow 
pulse  may  appear;  while  the  loss  of  weight  continues.  Only  after  several 
days,  or  even  during  the  second  week,  does  the  weight-curve  become  station- 
ary and  the  other  symptoms  begin  to  disappear  (Fig.  82). 

The  danger  of  breast-milk  feeding  is  greatly  reduced  and  favorable 
outcome  enhanced  by  adding  200  to  300  c.c.  of  buttermilk  or  fat-free  milk 
without  carbohydrate  addition  to  the  daily  allowance  of  mother's  milk  at 
the  outset.  This  prevents  the  continued  loss  of  weight  since  the  high  whey 
content  favors  water  retention.  As  the  amount  of  breast-milk  can  be 
increased,  the  additional  fat-free  milk  can  be  gradually  reduced.  It  is 
better,  however,  not  to  stop  it  entirely  for  slight  losses  of  weight  may  result. 

Now  follows  a  period  of  varying  duration,  sometimes  continued  for 
several  weeks,  during  which  the  weight  remains  stationary,  while  the  im- 
provement in  the  general  condition  co.ntinues.  The  inexperienced  advisor 
concludes,  therefore,  that  the  milk  of  the  wet-nurse  is  not  good  and  recom- 
mends a  change.  This  is  a  mistake.  We  have  to  deal  with  a  period  of  repair 
during  which  the  body  is  rebuilding  without  being  able  to  attain  any 
appreciable  increase,  partly  because  of  still  inadequate  absorptive  power 
and  partly  because  breast-milk,  poor  in  protein  and  salts,  affords  so  little 
material  for  cell-growth.  Only  after  this  period  does  an  increase  of  weight 
occur.  The  period  of  repair  may  be  shortened  by  giving  suitable  addi- 
tional food;  the  best,  probably,  being  buttermilk  to  which  carefully  regu- 
lated proportions  of  dextrin  and  maltose  preparations  or  malt  soup  are 
added.  This  supplemental  food  should  not  be  given  before  the  fourth 
week  and  then  at  only  one  meal  a  day.  The  addition  of  powdered  casein 
is  often  beneficial. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


285 


Complete  recovery  cannot  be  expected  in  less  than  two  to  three,  months. 
Not  until  this  period  of  time  has  passed  should  a  return  to  artificial  food  be 
considered.  It  is  advisable  to  precede  the  discontinuance  of  breast-milk 
with  small  artificial  feedings,  for  there  may  be  an  idiosyncrasy  for  cow's 
milk.  If  it  is  impossible  to  obtain  breast-milk  for  the  patient  suffering  from 
decomposition,  the  treatment  to  be  followed  should  be  that  recommended 
for  dyspepsia.  Buttermilk,  or  milk  poor  in  fat,  diluted  with  gruels  should 
receive  first  consideration.  But  while  with  breast-milk  the  intestine  soon 
recovers  to  such  an  extent  that  it  is  possible  to  give  adequate  quantities  of 


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FIQ.  82.— Recovery  of  a  case  of  decomposition  treated  with  breast-milk.  Aggravation  when  breast- 
milk  was  first  given  shown  by  subnormal  temperature  and  disturbances  of  weight.  Then  for  two  weeks 
no  change  in  weight.  Increase  occurred  after  addition  of  buttermilk  (Bm).  +  =  pathologic  stool; 

I   =  normal  stools. 

food,  the  slightest  increase  in  artificial  feeding  may  produce  a  recurrence  of 
the  diarrhoea  or  an  entire  arrest  of  improvement.  No  gain  is  to  be  hoped  for 
from  the  continuation  of  the  infant's  former  food,  or  from  the  feeding  of 
gruel  soups,  which  are  hazardous  because  of  the  danger  of  inanition. 
The  prospect  of  good  results  under  artificial  feeding  especially  with  younger 
children,  is  slight.  Recent  experience,  however,  has  shown  that  the  pos- 
sibility of  recovery  is  considerably  enhanced  by  the  use  of  protein-milk  or 
like  preparations. 

The  object  of  protein-milk  (Eiweiss  Milch),  is  to  avoid  as  fully  as  pos- 
sible the  occurrence  of  injurious  acid  fermentation.  This  is  accomplished 
by  the  reduction  of  the  milk-sugar  content  of  the  milk  by  a  dilution  of 
whey,  which,  in  itself,  improves  the  tolerance  of  the  intestine  for  sugar,  and 


286  TEXT-BOOK  OF  PEDIATRICS 

by  the  subsequent  addition  of  large  quantities  of  protein  which  tend  to 
counteract  the  acid  fermentation  by  the  development  of  an  alkalin  reaction. 

This  preparation  is  made  in  the  following  manner:  One  litre  (1  quart) 
of  milk  is  warmed  over  a  water-bath  to  98°  F.  and  curdled  with  one  table- 
spoonful  essence  of  pepsin.  The  whey,  containing  the  sugar,  is  separated 
from  the  curd  by  straining  through  cheese  cloth  (one-half  hour).  The  curd, 
mixed  with  one-half  litre  (1  pint),  of  water,  is  then  rubbed  through  a  fine 
wire  milk  strainer  two  or  three  times  without  excessive  pressure;  and  to  it 
one-half  litre  (1  pint),  of  good  buttermilk  is  added.  Finally  the  required 
amount  of  a  malto-dextrin  preparation  (dextri-maltose),  is  added  and  the 
mixture  is  brought  to  the  boiling  point  stirring  constantly.  The  curd  should 
not  form  lumps,  the  mixture  resembling  a  very  thin  porridge  when  shaken. 

The  preparation  is  sterilized  by  boiling  with  constant  energetic  stirring, 
which  is  best  done  with  a  "  Dover"  egg-beater.  If  insufficiently  stirred,  the 
protein  becomes  tough  and  the  mixture  is  useless. 

Separate  feedings  must  be  warmed  gradually  and  high  temperatures 
should  be  avoided.4  Benzosulphinidum  (saccharin),  may  be  added  to 
sweeten. 

Protein-milk  contains  3  per  cent,  casein;  2.5  per  cent,  fat;  1.4  per  cent, 
sugar  of  milk;  and  about  0.5  per  cent.  ash.  Its  food  value  is  four  hundred 
and  fifty  calories  per  litre. 

A  number  of  food  mixtures  based  upon  the  principle  of  protein-milk  have 
been  devised.  It  has  been  our  experience  that  some  of  these  have  the  cer- 
tain effect  of  the  original  protein-milk.  Among  others  may  be  mentioned : 
larosan  and  protolac,  casein  calcium  preparations.  Twenty  grams  (2-3 
ounces),  of  this  are  added  to  one  litre  (1  quart),  of  equal  parts  whole  milk 
and  water.  Feer's  protein-cream-milk  is  prepared  by  adding  50  grams  of 
20  per  cent,  cream,  10-50  grams  dextri-maltose,  and  15  grams  calcium 
caseinate  to  500  c.c.  (1  pint),  of  whole  milk  and  600  c.c.  (18  ounces)  of 
water.  The  protein-milk  itself  may  be  most  easily  prepared  according  to 
the  directions  of  Engel  or  those  of  Mueller-Kran.  Engel  accomplishes  the 
fine  division  of  casein  which  is  so  important,  by  using  a  special  rennet 
tablet  to  curdle  the  milk  after  it  has  been  boiled.  Unfortunately,  the 
coagulation  is  not  always  complete  with  these  tablets;  Mueller  and  Kran, 
therefore,  recommend  the  following  process:  Mix  one  litre,  (1  quart),  of 
buttermilk  with  an  equal  quantity  of  water,  boil  and  make  up  to  two  litres 
(2  quarts),  with  water.  Let  the  mixture  stand  for  thirty  minutes  until  the 
casein  settles  to  the  bottom.  Remove  1125  c.c.  (36  ounces),  of  the  fluid 
from  the  top  by  means  of  a  dipper.  To  the  remainder  add  125  c.c.  (3^6 
ounces)  of  20  per  cent,  cream  and  make  up  to  a  litre  again  with  water. 

The  advantage  of  protein-milk  feeding  lies  in  the  fact  that  a  return  to  the 
full  amount  of  nourishment  required  may  be  made  more  rapidly  than  with 

4  Difficulty  is  frequently  experienced  in  the  preparation  of  protein-milk.  In  a  poor 
preparation,  the  curative  action  is  often  lost,  the  child  refuses  it.  or  quite  frequently 
vomiting  results.  For  this  reason,  it  has  been  prepared  commercially  and  may  be 
obtained  in  the  powdered  form. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


287 


any  other  food,  without  causing  a  recurrence  of  the  fermentation  processes. 
The  danger  of  inanition  is  thus  excluded  and  repair  is  hastened. 

In  early  decomposition  and  in  dyspepsia  it  is  customary  to  begin,  after 
twelve  hours  of  starvation,  by  giving  300  c.c.  (10  ounces),  of  food,  with  at 
least  3  per  cent,  or  even  5  per  cent,  dextri-maltose,  in  five  or  six  feedings. 
Milk-sugar  is  not  advisable,  nor  is  the  cane-sugar  likely  to  produce  good 
results.  The  additional  fluid  required  is  given  in  the  form  of  weak  tea. 

The  quantity  of  protein-milk  is  increased  in  the  succeeding  days  without 
regard  to  the  condition  of  the  stools,  giving  an  additional  100  c.c.  every 
second  day,  or  even  more  frequently  if  the  stools  are  formed,  until  a  daily 
total  of  180-200  c.c.  per  kilo  is  reached.  The  total  feeding  should  not  exceed 


Week 


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5% 
Malt. 


Stool 

FIG.  S3. — Typical  recovery  of  case  of  decomposition  on  protein  milk  (black).  Rapid  disappearance 
of  the  diarrhoea  (+)  with  the  appearance  of  soap  stools  (D)  while  the  weight  remains  stationary. 
Later  undisturbed  growth  on  ordinary  milk  mixture.  . 

1000  c.c.  In  typical  cases,  the  dry-soap  stool  is  formed  on  the  first  or  second 
day;  the  weight  soon  remains  stationary,  and  the  child  is  moving  on  to 
uninterrupted  recovery  (Fig.  83). 

When  the  quantity  of  food  has  been  brought  up  to  the  required  amount, 
without  regard  to  whether  the  stools  are  infrequent  or  still  numerous,  the 
addition  of  carbohydrates  should  be  made  and  increased  gradually  to 
five  per  cent.  If  possible,  the  carbohydrate  addition  is  increased  up  to  five 
per  cent,  in  the  course  of  ten  day?.  If  the  weight  remains  stationary  and  the 
stools  are  homogeneous,  even  though  they  are  not  formed,  the  sugar  may 
be  increased  to  even  more  than  6-10  per  cent,  and  1  per  cent,  to  2  per  cent, 
carbohydrates  in  the  form  of  flour  may  be  added. 

In  advanced  cases  of  decomposition,  the  intestine  must  be  emptied  as 
rapidly  as  possible.  In  spite  of  the  danger  of  starvation,  a  hunger  period 


288  TEXT-BOOK  OF  PEDIATRICS 

of  from  six  to  twelve  hours  cannot  be  avoided.  After  this  200-300 
c.c.  of  protein-milk  is  to  be  given  in  frequent  feedings  (eight  to  ten  in  num- 
ber), during  the  first  twenty-four  hours  with  a  rapid  increase  in  the  quantity 
of  food  and  a  decrease  in  the  number  of  feedings;  to  which,  \\ithinaweek, 
carbohydrates,  in  quickly  increased  amounts,  should  be  added.  If  the  loss 
of  weight  does  not  cease  within  the  first  three  or  four  days  and  there  is  a 
tendency  to  subnormal  temperature  and  exhaustion,  even  though  the  stools 
are  frequent,  the  carbohydrates  should  be  further  increased,  in  the  effort 
to  stop  the  condition. 

Treated  in  this  manner,  the  number  of  unsatisfactory  cases  is  happily 
•  a  small  one.  It  is,  of  course,  impossible  to  save  children  in  whom  the  ter- 
minal comatose  symptoms  have  developed.  Experience  has  shown  that 
several  common  mistakes  are  made  in  the  treatment  with  protein-milk, 
which  are  responsible  for  seeming  failures.  They  all  arise  from  further 
injury  to  the  patient  through  inanition  or  carbohydrate  starvation.  Among 
these  errors  may  be  mentioned:  (1)  the  too  gradual  increase  of  quantity, 
thereby  lengthening  unduly  the  period  of  underfeeding  and  aggravating  the 
condition;  (2)  the  tardy  addition  of  the  carbohydrates  and  their  use  in 
insufficient  quantity;  (3)  an  arrest  of  the  increase  of  food  quantity  and 
especially  of  the  carbohydrates  when  the  stools  do  not  immediately  improve; 
(4)  a  decrease  of  the  amount  of  food  and  particularly  of  the  carbohydrate 
when  diarrhoea  reappears,  or  when  temperature  rises,  or  a  loss  of  weight 
occurs.  All  these  errors  are  to  be  avoided.  Only  when  a  sudden  decline 
in  weight  occurs  and  severe  diarrhoea  sets  in,  should  the  volume  of  the  food 
be  slightlyreduced  and  the  carbohydrate  lowered  to  three  per  cent.,  ju'st  as  is 
often  necessary  in  dyspepsia  or  intoxication.  After  the  disappearance  of 
these  symptoms,  the  return  to  full  feeding  should  be  made  as  rapidly  as 
possible.  In  feeding  the  protein-milk  the  food-stuffs  are  less  frequently 
responsible  for  such  remissions  than  are  the  accidental  infections. 

During  the  first  part  of  the  period  of  treatment  with  protein-milk, 
tendencies  to  temporary  aggravation,  similar  to  those  which  occur  when  the 
infant  is  fed  upon  breast-milk,  occur;  but  this  should  not  hinder  us  from 
increasing  the  quantity  of  food.  Rapid  improvement  usually  follows,  pro- 
vided enough  carbohydrate  is  supplied. 

Protein-milk  feeding  may  be  continued  for  six  to  eight  weeks  in  young 
infants;  in  older  children  from  four  to  six  weeks.  After  these  periods,  the 
repair  of  the  disease  condition  will  have  progressed  so  far  that  milk  mix- 
tures, suited  to  the  age  of  the  child,  will  be  taken  care  of.  It  is  best  to  dis- 
continue the  protein-milk  at  once,  replacing  all  the  feedings  with  milk 
mixtures.  If  a  relapse  occurs,  it  may  be  necessary  to  return  to  the  protein- 
milk  treatment. 

In  a  child  who  has  suffered  a  disturbance  of  nutrition  we  may  be  assured 
of  a  complete  recovery  only  when  through  a  sustained  period  of  feeding 
with  ordinary  milk-mixtures,  within  a  normal  range  of  quantity,  the  devel- 
opment continues  its  uninterrupted  course  (Fig.  83). 

In  the  child  with  decomposition,  medication  is  necessary  only  when  a 
tendency  to  collapse  occurs.  Stimulants  may  be  used,  e.  g.,  citrated  caffein; 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  289 

caff  em  with  sodium  benzoate,  in  0.5  to  1  per  cent,  solution,  teaspoonful 
doses,  four  to  five  times  daily;  camphor,  a  10  per  cent,  solution  in  oil,  five 
to  ten  minims  subcutaneously,  every  two  hours ;  brandy,  ten  drops,  several 
times  a  day.  During  the  early  period  of  the  illness,  artificial  heat,  by  means 
of  hot  water  bottles  or  warm  ba+hs,  36°-40°  C..  (96°-104°  F.)  should  be 
applied ;  or,  if  possible,  the  child  may  be  kept  in  an  incubator.  Care  should 
be  taken  to  avoid  overheating,  for  the  child  with  decomposition  is  especially 
prone  to  heat  injury.  The  attempt  to  replace  losses  of  water  by  means  of 
normal  salt  solution  is  not  efficacious  in  this  condition,  because  the  salt 
does  not  cause  water  retention,  and  because,  in  decomposition,  it  may 
produce  edema. 

For  hemorrhage  from  duodenal  ulcers,  the  treatment  recommended  for 
bleeding  of  the  new-born  in  that  section,  is  effective. 

B.  NUTRITIONAL  DISTURBANCES  WITH  Toxic  MANIFESTATIONS 
I.  Acute  Dyspepsia 

Symptoms. — Acute  dyspepsia  is  distinguished  from  the  dyspeptic  form 
of  dystrophy  by  its  sudden  onset  and  severe  clinical  manifestations.  An 
infant  that  has  been  doing  very  well  and  apparently  is  developing  normally, 
suddenly  develops  severe  gastro-intestinal  symptoms.  Nausea  and  vomit- 
ing may  precede  the  more  marked  signs,  but  very  soon  the  bowels  become 
extremely  loose.  The  stools  are  \vatery  with  much  gas  and  frequent.  The 
intensity  of  the  diarrhoea  is  usually  greater  than  in  the  chronic  dyspepsia. 
In  other  respects,  the  difference  between  the  two  conditions  is  rather  one  of 
degree  only.  All  the  symptoms  of  chronic  dyspepsia  are  also  seen  in  the 
acute,  but  are  more  severe.  This  is  especially  true  of  the  alimentary  fever 
which  may  be  very  high  in  the  acute.  Because  of  the  greater  severity  of  the 
symptoms  of  this  form  of  dyspepsia,  it  may  be  considered  as  a  forerunner  of 
intoxication  and  treated  as  such.  Improper  treatment  very  frequently  com- 
pletes the  transition. 

The  remaining  symptomatology,  metabolism  and  pathogenesis  is  iden- 
tical with  that  of  dystrophy  with  dyspepsia. 

Etiology. — In  most  cases,  a  parenteral  infection  is  probably  responsible 
for  the  sudden  disturbance.  When  no  infectious  process  can  be  demon- 
strated the  cause  may  lie  in  an  excess  of  carbohydrate  in  the  mixture  or  may 
be  found  in  a  sudden  overfeeding. 

Diagnosis. — The  question  whether  the  sudden  serious  condition  arises 
in  a  previously  normal  infant  or  whether  it  is  an  exacerbation  of  an  old  dis- 
turbance of  the  nutritional  function,  or  whether  the  patient  is  one  of  the  not 
uncommon  constitutionally  "  tropho-labile "  infants,  must  be  carefully  an- 
swered, for  the  treatment  depends  entirely  upon  this. 

Prognosis. — The  result  of  proper  dietetic  treatment  in  a  child  that  has 
been  well  up  to  the  time  of  the  acute  attack  is  good.  In  very  young  infants, 
the  danger  of  transition  into  decomposition  is  constantly  present.  In  older 
children,  the  possibility  of  transition  into  chronic  dyspeptic  dystrophy  must 
be  kept  in  mind. 
10 


290  TEXT-BOOK  OF  PEDIATRICS 

Treatment. — In  the  acute  form  of  dyspepsia  in  previously  healthy  chil- 
dren the  treatment  may  be  based  upon  the  fact  that  the  patient  has  an 
uninjured  tolerance  and  that  the  cause  of  the  sudden  diarrhosa  is  due  to  an 
acute  discrepancy  between  the  food  ingested  and  the  metabolic  capacity. 
In  such  a  case,  rapid  recovery  may  be  expected  after  a  short  period  of  free 
purgation.  Accordingly,  the  following  procedure  is  recommended  for  the 
typical  case.  (1)  A  starvation  period  of  not  more  than  six  to  twelve  hours. 
During  this  time  liberal  amounts  of  water  sweetened  with  benzosulphinidum 
(saccharin)  are  given.  The  emptying  of  the  gastro-intestinal  tract  may  be 
made  more  complete  by  the  use  of  gastric  lavage  and  high  enemata.  If  the 
diarrhoea  is  moderate,  castor  oil,  one  tablespoonful  may  be  indicated.  (2) 
After  this,  the  food  is  again  given  but  in  greatly  reduced  amounts.  Usually 
only  about  one-third  of  the  caloric  requirement  is  supplied.  Large  amounts 
of  fluids  are  essential  and  the  quantity  may  be  made  up  by  diluting  the  food 
or  by  giving  water  flavored  with  tea  and  sweetened.  (3)  Rapid  increase  of 
the  food  quantity  should  follow,  so  that  the  full  requirement  is  again  given 
by  the  second  or  third  day.  The  underfeeding  period  must  be  limited  to  the 
shortest  possible  time. 

As  to  the  food,  it  must  remembered  that  the  diarrhoea  will  disappear  no 
matter  what  food  is  used,  if  the  quantity  is  small  enough.  This  is  true  even 
though  the  food  that  caused  the  disturbance  is  continued.  As  in  chronic 
dyspepsia,  however,  those  mixtures  containing  the  less  fermentable  carbo- 
hydrates give  more  certain  results.  But  the  carbohydrate  additions  cannot 
be  omitted  entirely  except  for  a  very  short  period  of  time.  Mixtures  high 
in  fats  are  contraindicated  because  of  the  unfavorable  action  of  fatty  acids 
on  the  intestine  already  injured  by  the  fermentation.  Accordingly,  in 
mild  cases  the  feeding  is  best  begun  with  a  simple  gruel,  to  which  may  be 
added  small  amounts  of  partially  skimmed  milk  with  the  addition  of  a  less 
fermentable  carbohydrate  using  flour,  dextrinized  flour,  maltose  and  dex- 
trin preparation  but  no  milk-sugar.  Skimmed  lactic-acid  milk  or  butter- 
milk is  useful,  and  calcium  caseinate  may  be  of  benefit.  Protein-milk  is 
especially  good.  In  fact  the  foods  used  in  the  chronic  form  of  dyspepsia  are 
also  indicated  in  the  acute  stage. 

Gruels  or  flour  soups  may  be  used  in  infants  older  than  three  months. 
Several  objections  can  be  raised  against  this  treatment,  however.  In  the 
first  place,  there  is  distinct  danger  of  qualitative  inanition  (flour-feeding 
injury)  due  to  the  lack  of  protein  and  fat,  and  the  danger  that  the  food  will 
be  continued  longer  than  was  intended.  In  the  second  place,  the  change  to 
a  mixture  containing  milk  is  often  very  difficult  because  of  the  recurrence  of 
diarrhoea  when  even  small  amounts  of  milk  are  added.  If  the  gruel  treat- 
ment is  used,  it  is  well  to  add  a  small  amount  of  calcium  caseinate  and  a  few 
spoonfuls  of  meat  broth  for  the  mineral  salts,  and  even  then  the  mixture 
must  not  be  continued  for  more  than  three  or  four  days. 

Cases  treated  according  to  the  above  method  of  procedure  recover 
rapidly  (Fig.  84).  After  a  sharp  decline  of  the  weight-curve,  as  a  result 
of  the  starvation  period,  the  line  gradually  becomes  less  steep  and  after  a 
day  or  so  remains  stationary.  At  the  same  time,  the  temperature  also 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


291 


becomes  normal  and  the  stools,  less  frequent,  are  more  formed.  As  soon  as 
the  caloric  requirement  is  completely  covered,  the  weight  increases.  At 
times  it  may  be  necessary  to  add  more  carbohydrate  to  produce  an  increase, 
and  this  may  be  done  even  though  the  stools  are  not  entirely  formed  and 
still  more  frequent  than  normal.  If  improvement  is  delayed,  or  there  is  still 
some  loss  of  weight,  no  further  time  can  be  lost  before  instituting  the  treat- 
ment for  the  severe  forms  of  dystrophy  with  dyspepsia,  or  for  decomposition. 
No  greater  harm  can  befall  these  patients  than  persisting  in  underfeeding. 
In  those  forms  of  acute  dyspepsia  arising  from  parenteral  infection,  such 
as  coryza  or  grippe,  strenuous  interference  is  contraindicated  and  the  case 
should  be  treated  expectantly.  As  long  as  the  infection  does  not  produce 
marked  loss  of  weight,  it  will  hardly  be  found  necessary  to  change  the  food. 

Weight 


Stool 


3900 
3800 
3700 


3500& 
34WJ. 
700J6 
600 
WO 
WO 
300 
ZOO 
100 
0 


ullr  jr  y 


Sugar. 


Milk. 


Fia.  84.—  Dyspepsia 
lypical  course 


with  alimentary  fever  after  feeding  with  sweetened  buttermilk. 
of  recovery.     +=  pathologic  stool;   I  =  normal  stool. 


After  the  infection  has  disappeared,  the  digestive  function  frequently  returns 
to  normal  without  therapeutic  alterations  of  the  diet.  Only  when  there  are 
severe  losses  of  weight,  or  when  the  diarrhrea  persists  after  the  infection 
has  been  overcome,  will  it  be  necessary  to  institute  the  procedure  described. 

II.  Intoxication 

(ALIMENTARY  TOXICOSIS,  ENTERO-CATARRH,  CHOLERA  INFANTUM,  ETC.) 
Intoxication  may  arise  gradually  from  the  acute  form  of  dyspepsia,  or  it 
may  at  any  time  appear  as  an  acute  catastrophy  in  the  chronic  course  of  a 
disturbance  of  the  type  of  dystrophy  or  decomposition.  Furthermore,  it 
may  occasionally  develop  repeatedly  in  the  same  infant.  In  the  previously 
comparatively  normal  child,  the  development  of  intoxication  requires  a 
rather  severe  injury,  but  in  infants  with  decomposition,  a  very  slight  irreg- 
ularity of  the  diet  or  a  mild  added  infection  brings  on  the  dire  symptoms 
very  quickly. 


292 


TEXT-BOOK  OF  PEDIATRICS 


Symptoms. — The  first  sign  of  the  toxic  action  of  food  is  the  fever.  In  its 
mildest  forms  there  is  a  slight  rise  above  the  daily  maximum  of  tempera- 
ture; at  other  times,  subfebrile  temperatures  are  seen;  or  even  high  fever 
may  occur. 

Alimentary  fever,  with  dyspeptic  stools  continuing  for  a  long  period, 
may  be  the  only  symptom  of  the  toxic  nature  of  the  disturbance.  This 
condition  does  not  necessarily  preclude  increase  of  weight.  In  most  cases, 
however,  additional  indications  are  seen,  such  as  loss  of  weight,  weakness, 
and  symptoms  of  disorder  of  the  kidney.  From  these  prodromes,  complete 
intoxication  may  develop  more  or  less  rapidly  and  even  acutely. 

Typical  and  fully  developed  alimentary  intoxication  may  be  recognized 
by  the  following  symptoms:  Fever,  collapse,  severe  diarrhoea,  disturbances 

of  the  sensorium,  sighing  respira- 
tion, albuminuria,  casts,  glyco- 
suria,  leucocytosis,  and  abrupt 
loss  of  weight.  Disturbance  of 
the  sensorium  is  seen  early,  in  the 
form  of  abnormal  lassitude  and 
drowsiness.  The  patient  is  un- 
usually quiet  and  lies  very  still 
or  relapses  rapidly  into  lethargy 
after  being  aroused.  When  he 
opens  his  eyes,  the  look  seems 
vacant  and  can  be  engaged  only 
with  extreme  difficulty.  The  us- 
ually lively  expression  is  covered 
by  a  mask-like  stare.  Slight  shad- 
ows lie  about  the  eyes.  In  place 
of  the  ordinarily  rapid  movements 
of  the  healthy  child,  infrequent, 
slow,  listless,  apathetic  and  in- 
direct gestures  are  observed.  The 
normal  pose  of  the  limbs  is  replaced  by  unusual  attitudes  continued  for  a 
long  time  and  due  to  a  cataleptic  condition.  The  so-called  "boxer's  posi- 
tion" is  very  frequent  among  these  peculiar  poses  (Fig.  85). 

In  severe  cases  true  coma  may  follow  this  stage.  From  this  the  child 
awakens  with  severe  jactitation  and  loud  shrieks.  As  the  condition  pro- 
gresses, these  become  less  frequent  and  the  child  lies  moaning  in  a  deep 
stupor.  Convulsions,  other  symptoms  of  meningeal  and  cerebral  irritation 
and  paralyses  frequently  occur. 

Pyrexia  or  even  hyperpyrexia  is  common;  normal  or  subnormal  temper- 
atures occurring  only  in  children  with  decomposition  and  intoxication. 

The  respiration  is  of  that  peculiar  type  frequently  designated  as  "toxic 
breathing."  The  rhythm  is  long,  deep,  without  pause  and  of  increased 
rapidity,  at  times  resembling  that  of  the1  "hunted  beast." 

During  the  prodromal  period,  the  stools  resemble  those  of  dyspepsia  or 
decomposition.  At  the  height  of  the  illness  they  become  very  numerous, 


FIG.  85. — Facial  expression  of  child  with  intoxication. 
Indication  of  "boxer's  position"  (Dr.  Dessauer^ . 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


293 


watery,  of  a  greenish-yellow  color,  wanting  in  substance  and  containing 
flakes  of  mucus.  The  reaction,  strongly  acid  in  the  beginning,  may  change 
to  an  alkalin  one  on  account  of  the  excessive  intestinal  secretion. 

Vomiting  is  frequent  and,  in  definitely  established  cases,  very  violent. 
It  may  take  so  important  a  place  in  the  symptom-complex  that  the  desig- 
nation of  diarrhoea  with  vomiting  is  probably  justified.     In  the  severest 
forms,  the  vomited  matter  consists  of 
dark,    "coffee-grounds"    masses    which 
indicate  gastric  hemorrhage. 

Sharp  decline  in  the  weight-curve  is 
caused  by  the  excessive  loss  of  water. 
Five  hundred  to  one  thousand  grams 
(1-2  pounds)  or  more,  may  be  lost  in  a 
few  days.  The  skin  becomes  dry  and 
plastic,  so  that  if  pinched  the  impress 
remains  (Fig  86) ;  the  features  are  sharp 
and  the  fontanelle  sunken.  There  may 
be  muscular  hypertonicity  and  painful 
cramps  or  contractures,  especially  of  the 
leg  muscles. 

The  drying  out  of  the  tissues  is  prob- 
ably the  cause  of  collapse,  which  is 
accompanied  by  a  small  pulse,  dull  and 
faint  heart  sounds,  and  cold  and  cyanotic 
extremities.  The  polycythaemia  pro- 
duced by  the  extraction  of  fluid  from 
the  blood  is  probably  the  cause  of  the 
characteristic  pale  bluish-yellow  color  of 
the  skin.  The  urine  contains  albumin 
and  usually  much  sediment  with  hyalin 
and  granular  casts.  The  occurrence  of 
glycosuiia5  is  purely  dietetic;  that  is,  it 
disappears  upon  the  withdrawal  of  food. 
The  sugar  in  the  urine  is  of  the  form 
ingested.  When  the  infant  is  fed  mix- 
tures containing  sugar  of  milk,  lactose 
and  galactose  are  found  in  the  urine;  with  othe,r  foods,  other  sugars 
are  present. 

There  is  always  a  leucocytosis,  the  maximum  count  being  as  high  as 
thirty  thousand. 

In  severe  cases,  fat  sclerema,  that  peculiar  hardening  of  the  skin  and  sub- 
cutaneous tissues,  beginning  on  the  legs  and  buttocks  and  finally  extending 

5  The  demonstration  of  sugar  in  the  infant's  urine  is  not  a  simple  matter.  In  doubt- 
ful cases,  the  osazone  test  should  be  used,  in  addition  to  the  Trommer's  and  Nylander's 
tests.  In  the  Trommer's  test  the  urine  should  be  boiled  for  quite  a  long  time,  since  the 
cuprous  oxide  is  not  precipitated,  in  the  presence  of  much  ammonia,  by  simply  heating. 
The  exact  identification  of  the  sugar  can  be  made  only  by  microscopic  study  of  the  pre- 
cipitated osazone. 


FIG.  86. — Severe  dehydration,  showing  the 
loss  of  elasticity  of  skin.  Cholera  infantum. 
Two-year-old  child. 


294  TEXT-BOOK  OF  PEDIATRICS 

over  the  whole  body,  may  develop.  The  nature  of  this  change  has  not  been 
determined.  The  explanation,  formerly  given,  of  a  solidification  of  the 
infantile  fat  of  high  melting  point  by  the  subnormal  temperatures,  is  con- 
tradicted by  clinical  observations. 

The  large  number  of  symptoms  suggests  the  complexity  of  the  disease. 
The  clinical  picture  is  varied  by  the  prominence  of  one  or  another  indication 
in  the  symptom-complex.  Soporific,  choreiform  arid  cerebral  types  may  be 
differentiated;  the  latter  probably  corresponds  to  the  hydrocephaloid  type 
of  the  older  authorities. 

Pathologic  Anatomy. — The  structural  changes  are  not  great  and  do  not 
aid  in  the  understanding  of  the  severe  clinical  findings.  A  serous  or  sero- 
hemorrhagic  catarrhal  condition  is  found  in  the  stomach  and  intestine. 
The  gastric  mucous  membrane  is  covered  with  tough  bloody  mucus.  The 
intestinal  walls  are  injected,  of  a  deep  red  color,  and  edematous.  In  the 
jejunum,  there  is  a  disseminated  macular  hyperaemia,  with  punctate  or 
streaked  hemorrhages.  Peyer's  patches  are  swollen  and  surrounded  by  a 
slight  hyperaemia.  Microscopically,  the  intestine  may  appear  practically 
normal.  More  frequently,  however,  we  see,  besides  a  round  cell  infiltration, 
mucoid  degeneration  of  the  goblet  cells.  In  severe  cases  there  is  destruction 
and  marked  loss  of  epithelium.  In  other  organs,  mild  parenchymatous 
changes  occur.  In  the  liver,  a  capillary  hyperaemia  is  a  common  occurrence 
and  degeneration  of  the  endothelial  and  liver  cells  is  noted.  Hyperacidity 
of  the  liver  tissues  and  of  the  muscular  tissues  may  be  demonstrated  by 
special  staining  methods. 

Etiology. — The  great  resemblance  of  these  symptoms  to  those  of  real 
cholera  and  cholera  nostras  in  the  adult,  described  in  the  older  terminology, 
was  the  reason  for  the  acceptance  of  an  infectious  etiology  in  the  intoxica- 
tion of  the  infant.  Even  though  toxic  symptoms  may  raise  secondarily  in 
enteral  and  parenteral  infections  of  the  young  child,  this  explanation  is 
hardly  tenable.  Not  only  has  it  been  impossible  to  demonstrate  specific 
organisms,  but  the  most  careful  clinical  observations  show  that  we  have  to 
deal  with  a  condition  of  alimentary  poisoning  in  which  the  question  of 
specific  pathogenic  germs  is  not  to  be  considered;  but  in  which  fermentation 
products  of  the  food  or  constituent  parts  of  the  food  itself  are  the  etiologic 
factors.  The  importance  of  preformed  poisons  in  the  food  (exogenous  milk 
decomposition),  must  also  be  excluded,  since  intoxication  may  arise  with 
absolutely  aseptic  food. 

Cases  are  seen  in  which  the  symptom-complex  is  of  purely  alimentary 
origin.  In  other  and  probably  more  frequent  cases,  there  may  be  a  mild 
infective  process  causing  dyspeptic  manifestations  from  which  the  intoxica- 
tion develops  as  a  secondary  alimentary  complication.  After  the  infection 
has  been  relieved,  the  intoxication  persists  and  forms  the  essential  part  of 
the  picture.  A  third  large  group  shows  no  relation  to  the  feeding  and  must 
therefore  be  considered  purely  infectious. 

The  etiologic  role  played  by  the  food  is  convincingly  shown  by  the  results 
of  the  withdrawal  of  food  and  the  inauguration  of  the  water-diet  for  thera- 
peutic purposes.  In  all  pure  cases,  uncomplicated  by  infection,  we  observe 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


295 


a  critical  drop  in  temperature  upon  the  cessation  of  feeding.  In  almost  all 
such  cases,  which  are  not  in  extremis  a  critical  detoxication  also  occurs 
If  the  food  quantit}'  be  increased  too  rapidly  after  the  hunger  period, 
a  relapse  follows.  Thorough  investigations  have  shown  that  the  causation 
of  the  diarrhoea  and  the  fever  is  to  be  found  in  the  action  of  the  carbohy- 
drates of  the  food,  combined  with  the  whey  constituents  (Fig.  87).  If  these 
are  given  in  sufficiently  large  quantity,  their  pyrogenic  action  may  be  aug- 
mented by  the  toxic  effect.  Large  additions  of  fat  alone  may  exhibit  a 
toxic  action;  but  a  primary  fat  poisoning  is  possible  only  when  the  metabolic 
functions  have  been  previously  damaged  by  a  severe  sugar  injury,  or  by  an 
existing  decomposition,  or  by  severe  infection. 

THE  NATURE  OF  THE  Toxic  CONDITION;  ITS  PATHOGENESIS  AND  ME- 
TABOLISM.— So  far  as  the  results  of  investigation  of  the  metabolism  go,  at 
present  they  show  that  intoxication  is  due  to  an  insumciencyof  all  of  the  inter- 


6%  Without.       +  Sugar.   Without        +  Sugar. 

Sugar.  Sugar.  Sugar. 

Flo.  87. — Alimentary  fever  during  buttermilk  feeding,  produced  by  the  addition  of  sugar 
(shaded  days)  and  relieved  by  the  omission  of  the  sugar. 

mediate  metabolic  processes,  in  which  the  evidences  of  acidosis  are  especially 
prominent.  The  present  knowledge  of  the  metabolism  of  these  severe  general 
disturbances  permits  the  following  statements  as  to  theetiology.  Thereis,  no 
doubt,  a  far  reaching  injury  to  the  intestine  which  permits  abnormally  free 
osmosis  of  the  products  of  the  perverted  digestion  from  without  inward  and 
also,  unquestionably,  acts  in  the  opposite  direction.  This  condition  is 
caused  by  the  extreme  decomposition  of  the  ingested  food,  the  products  of 
which  affect  the  mucosa.  According  to  the  older  theory  this  abnormal  per- 
meability of  the  intestinal  lining  permits  the  absorption  of  bacterial  poisons, 
the  cause  of  the  fever  and  the  toxic  manifestations.  More  recently,  however 
the  blame  has  been  laid  on  the  sodium  salts,  sugar  and  protein,  for  clinical 
observation  on  the  pyretogenic  and  toxic  action  of  these  substances  make 
it  apparent  that  the  physicochemical  disturbance  must  be  taken  into  con- 
sideration. It  is  possible  that  the  portal  blood  carried  to  the  liver  is  in  a  con- 
dition of  osmotic  imbalance,  this  injures  the  liver  cells  resulting  in  catabolic 
products  which  are  causative  factors  of  free  purgation.  Some  experimental 
foundation  for  this  theory  has  been  brought  out.  If  the  diarrhoea  becomes 


296  TEXT-BOOK  OF  PEDIATRICS 

very  severe,  there  is  a  great  dehydration  and  ultimately  a  lack  of  water  in 
the  tissues.  In  such  a  condition  of  dehydration,  the  oxidation  processes 
would  naturally  be  impaired.  Very  probably  poisonous  derivatives  of  food 
proteins  or  of  body  protein  catabolism  carry  on  the  toxic  condition.  This 
would  place  great  emphasis  on  the  importance  of  the  acute  loss  of  water  in 
the  etiology  of  intoxication.  This  conception  is  supported  by  the  fact  that 
detoxication  always  occurs  as  soon  as  water  retention  is  established. 

Diagnosis. — The  alimentary  fever  is  to  be  distinguished  from  fever  due 
to  infection  in  that  it  is  always  abolished  when  food  is  withdrawn,  or  when 
a  marked  reduction  of  food  is  made.  In  a  general  way,  this  is  also  true  in 
case  of  alimentary  intoxication.  But  cases  with  severe  toxic  symptoms  are 
either  relieved  very  slowly  or  not  at  all  by  this  reduction.  Here,  no  doubt, 
the  continuation  of  the  symptoms  is  due  to  the  persisting  loss  of  water.  If 
it  is  possible  to  cause  water  retention  detoxication  at  once  begins.  These 
obstinate  forms  are  unquestionably  ones  in  which  the  intoxication  is  com- 
plicated with  infection,  the  condition  being  infectious  rather  than  purely 
alimentary.  In  other  cases  the  carbohydrate  and  salt  of  the  diet  are  so  low 
as  to  prevent  water  retention.  Finally,  the  bowel  condition  may  be  so 
serious  that  the  cessation  of  feeding  alone  will  not  result  in  sufficient  repair 
to  prevent  further  loss  of  water. 

Prognosis. — The  prognosis  is  influenced  less  by  the  severity  of  the 
clinical  findings  than  by  the  duration  of  the  toxic  condition,  as  well  as  by  the 
status  of  the  child  at  the  incidence  of  the  intoxication.  Acute  attacks,  in 
previously  healthy  children,  frequently  encountered  in  those  who  are  overfed 
upon  buttermilk  with  large  additions  of  sugar,  if  promptly  and  energetically 
treated  by  .correct  methods,  have,  in  spite  of  the  severity  of  symptoms, 
a  good  prognosis.  Long  duration  of  the  toxicosis  is  naturally  detrimen- 
tal even  to  such  children.  A  clinically  mild  attack  of  intoxication  in 
children  suffering  with  decomposition  is  very  dangerous;  because  it  is  liable 
to  overcome  the  remaining  tolerance  and  because  the  unavoidable  hunger- 
period  is  particularly  serious.  Every  infection  causes  an  irreparable  com- 
plication of  the  condition.  The  difficulty  of  dietetic  treatment  of  intoxication 
caused  by  infection  depends  (upon  the  severity  of  the  infection.  The 
weight-curve  gives  the  best  index  of  prognosis.  On  account  of  the  effect  of 
water  retention  upon  the  weight-curve,  the  prognosis  is  more  grave  the 
longer  the  time  required  to  bring  the  weight  to  the  horizontal. 

Treatment. — In  severe  cases,  the  complete  withdrawal  of  food  for  the 
removal  of  toxic  conditions  cannot  be  avoided.  The  free  supply  of  fluids 
must  not  be  interrupted  and  this  is  best  met  by  giving  large  quantities  of 
weak  tea.  Since  the  greater  danger  of  sugar  intoxication  is  avoided  by  dis- 
continuing all  other  feeding,  it  is  well  to  sweeten  the  tea  with  benzosulphi- 
nidum  (saccharin). 

In  order  to  arrest  the  drying  out  process  as  speedily  as  possible,  salt 
solutions  have  been  recommended  instead  of  tea;  [e.  g.,  physiologic  salt 
solution,  Heim-Johns'  solution  (NaCl  5.0,  NaHCO3  5.0,  Aq.  1000), 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  297 

Mery's  vegetable  bouillon,  or  Moro's  carrot  soup6].  All  of  these  solutions 
have  the  disadvantage  of  frequently  prolonging  the  pyrexia  through  the 
pyogenic  action  of  the  salt.  In  certain  circumstances,  they  even  aggravate 
the  toxic  condition.  They  should,  therefore,  be  well  diluted  (1:2  water), 
and  should  be  employed  only  after  the  elimation  of  the  poison  has  begun. 

No  objection  can  be  made  to  subcutaneous  injections  of  a  physiologic 
salt  solution,  if  contamination  of  the  water  is  avoided  by  distillation.  The 
0.3  per  cent,  solution  of  the  so-called  detoxicated  salt  solution  (7  gms.  NaCl, 
1  gm.  KC1  and  0.2  gm.  CaCl  in  1000  c.c.  water)  is  preferable  to  the  physio- 
logic solution.  This  solution  is  also  absorbed  very  rapidly  from  the  perito- 
neum and  may  be  given  under  conditions  of  ordinary  surgical  asepsis 
in  amounts  of  500  to  750  c.c.,  repeated  daily. 

The  intestine  may  be  emptied  rapidly  by  washing  the  stomach  and 
colon.  This,  however,  is  not  absolutely  necessary.  Cathartics  should  not 
be  used  in  severe  diarrhoea;  while  stimulants,  caffein  salts,  camphor, 
digalen,  }/£-l  drop  every  three  hours;  epinephrin,  1 : 1000, 0.5  c.c.  (7  minims) 
with  pituitrin  0.25  (grs.  ii)  intramuscularly  every  three  hours:  or  brandy 
cannot,  be  dispensed  with.  Tepid  baths  should  be  used  to  control  the  high 
temperature;  while  frequently  repeated  cold  packs  should  be  avoided  because 
of  the  danger  of  collapse.  If  the  skin  is  cool,  a  warm  mustard  bath  may  be 
considered.  Jactitation,  convulsions,  and  severe  attacks  of  pain  make  the 
exhibition  of  narcotics  desirable;  chloral,  however,  must  be  avoided  because 
it  may  produce-a  soporific  condition  lasting  for  days.  Veronal  0.075-.015  gm. 
(1-3  grs.),  or  sodium  diethylbarbituate,  0.05-0.1  gm.  (1-2  grs.)  per  dose,  is 
better.  Stomach  washing  and  local  anesthetics  are  most  useful  when  there 
is  vomiting.  (See  Pylorospasm.) 

In  favorable  cases  of  simple  intoxication,  the  poison  is  completely 
removed  in  from  twenty-four  to  thirty-six  hours  of  starvation  (Fig.  88). 
Although  the  child  grows  weak  and  thin,  it  is  lively,  its  eyes  are  clear  and 
the  bowel  movements  are  less  frequent.  After  such  a  period  of  starvation, 
it  is  absolutely  necessary  that  feeding  be  resumed.  The  prime  object  of 
treatment  should  be  to  keep  the  symptoms  of  intoxication  in  abeyance  by 
the  smallest  possible  amounts  of. food;  increasing  it  very  gradually  during 
the  first  few  days,  while  a  plentiful  supply  of  liquids  is  given. 

The  course  of  treatment  most  to  be  commended  is  the  feeding  of  breast- 
milk.  Even  with  this,  it  is  best  to  feed  small  quantities  frequently.  It  ifc 
well  to  begin  by  giving  the  child  5  c.c.  five  times  during  the  first  day,  10  c.c. 
five  times  or  5  c.c.  ten  times  on  the  second  day;  and  10  c.c.  ten  times  on  the 
third  day;  thereafter,  at  first  slowly,  and  then  more  rapidly,  giving  larger 
quantities  in  fewer  feedings.  The  sooner  the  danger  of  inanition  is  removed 
the  better;  on  the  other  hand,  great  care  must  be  exercised  to  avoid  an 
aggravation  of  the  condition  by  too  rapid  increase  of  food.  This  aggrava- 
tion is  shown  in  the  renewed  appearance  of  the  toxic  symptoms.  It  is  better 

6  Carrot  soup  is  prepared  as  follows :  One  pound  of  carrots  scraped,  cut  into  small 
cubes  and  boiled  one  to  two  hours.  The  soft  carrot  is  passed  through  a  fine  sieve,  into 
bouillon  made  with  one  pound  of  beef  in  one  litre  of  cold  water;  to  this  is  added 
one  teaspoonful  of  table  salt. 


298 


TEXT-BOOK  OF  PEDIATRICS 


to  feed  the  expressed  breast-milk  from  the  bottle  at  first;  and  often  it  is 
better  cold  than  warm.  After  a  few  days  of  feeding  by  this  method  the 
child  may  be  returned  to  the  breast. 

With  the  use  of  artificial  food,  detoxication  may  also  be  accomplished  if 
small  enough  amounts  are  fed.  The  mixture  must  naturally  be  one  in  which 
there  is  a  minimum  of  fermentable  carbohydrate  and  one  which  affords  the 
maximum  water  retention.  A  food  containing  very  little  fat.  and  sugar  and  a 


Weight. 


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and  whey  (buttermilk).     Reduction  of 
ich  the  amount  of  food  is  very  gradually 


liberal  amount  of  whey  fulfils  this  requirement  and  buttermilk  or  skimmed 
milk  without  additions,  are  ideal.  Whey  has  also  been  recommended  but 
has  no  advantage  over  buttermilk.  It  is,  in  fact,  less  satisfactory  because  of 
the  lack  of  casein  which  counteracts  fermentation.  The  dosage  and  number 
of  feedings  should  be  as  recommended  for  breast-milk.  Even  before  the 
weight-curve  becomes  stationary,  carbohydrate  may  be  added  and  then  the 
buttermilk  gradually  replaced  by  a  whole  milk  mixture.  After  this,  the 
treatment  is  that  described  for  dyspepsia. 

In  those  cases  in  which  the  poison  is  not  fully  eliminated,  cases  which 
were  formerly  classed  as  forms  of  mixed  alimentary  intoxication  and  infec- 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  299 

tion,  or  those  which  should  be  included  in  the  severe  type  of  decomposition, 
the  feeding  must  approximate  that  recommended  above.  Further  star- 
vation undoubtedly  causes  death.  The  only  possibility  of  recovery  lies  in 
giving  the  small  remnants  of  functional  ability  an  opportunity  to  recuperate 
with  a  dietary  as  large  as  they  can  utilize.  With  children  in  the  severer 
stages  of  decomposition  this  merely  prolongs  the  trouble,  while  with  infec- 
tions, on  the  other  hand,  the  disorder  is  frequently  overcome  and 
convalescence  sets  in.  It  is  better,  therefore,  to  rise  very  gradually  to  food 
quantities  which  are  just  sufficient  to  sustain  life  and  to  await  results. 
Hopeful  progress  with  these  children  may  be  expected  from  buttermilk  with 
thf>  addition  of  breast-milk  or  protein-milk,  with  a  five  per  cent,  carbohy- 
drate addition.  Protein-milk  in  itself  seems  to  fulfil  all  the  requirements  and 
may  be  used  without  fear,  if  given  in  the  same  dosage  recommended  for 
the  other  foods. 

INFECTION  AND  NUTRITION 

Attention  has  been  called  already  to  the  greater  predisposition  of  the 
child  with  disturbance  of  nutrition  to  infections.  As  an  actual  fact, 
in  but  very  few  cases  does  the  disturbance  run  its  course  without  bac- 
terial complications.  Of  most  frequent  occurrence  are  the  infections  of 
the  skin,  furunculosis  and  other  pyrodermias,  phlegmons  and  erysipelas; 
next  in  frequency  are  diseases  of  the  air  passages  and  lungs;  sepsis  and 
pyemia  with  their  varied  courses  follow;  pyelocystitis,  otitis,  and  infections 
of  cerebral  localization  also  occur.  These  infections  are  not  only  incurred 
more  readily,  but  because  of  the  reduced  resistance  they  run  a  more  severe 
course,  tend  to  spread  and  may  become  serious.  A  furuncle  may  increase  to 
a  phlegmon  which  extends  with  remarkable  rapidity;  severe  pneumonia 
may  follow  la  grippe,  etc.  The  slow  healing  of  the  infected  wounds  in  nutri- 
tionally disturbed  children  is  very  noticeable. 

In  turn,  the  course  of  any  disturbance  of  nutrition  is  unfavorably  influ- 
enced by  each  infection.  A  further  reduction  of  functional  energy  is  the 
inevitable  result  of  the  intercurrent  injury.  Every  degree  of  effect  may  be 
noted,  according  to  the  resistance  of  the  patient  and  the  virulence  of 
the  infection. 

An  infection  does  not  necessarily  produce  a  secondary  disturbance  of 
nutrition,  or  one,  at  least  of  a  severe  nature.  In  healthy  children,  it  fre- 
quently passes  without  loss  of  weight  or  even  with  a  continued  gain  in 
weight.  The  stools  may  remain  normal  (Fig.  89).  The  bowel  movements 
vary  in  different  infections;  hard,  formed  stools  may  occur  in  pyemia;  while 
la  grippe  and  colon  bacillus  infections  produce  thin,  mucoid  movements,  the 
infectious  nature  of  which  is  recognized  by  the  fact  that  they  are  uninflu- 
enced by  dietetic  therapy.  Loss  of  weight  in  these  cases  is  usually  due  rather 
to  diarrhoea  and  vomiting.  On  the  other  hand,  in  constitutionally  weak 
children  and  in  those  with  a  disturbance  of  nutrition,  unimportant  infec- 
tions (e.g.,  vaccination,  Fig.  90),  produce  serious  alimentary  injuries. 
Of  course,  healthy  children  may  be  nutritively  affected,  either  early  in  the 
course  of  a  highly  virulent  infection,  or  later  because  of  the  gradual  exhaus- 


300 


TEXT-BOOK  OF  PEDIATRICS 


Week 


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FIG.  89. — Course  of  severe  infection  in  patient  on 
protein-milk.  No  marked  disturbance  of  nutrition  (contin- 
ued gain  in  weight,  stools  but  little  more  frequent  and  but 
slightly  changed). 


tion  of  their  original  tolerance. 
The  diet  is  to  a  certain  degree 
important.  Other  conditions 
being  equal,  a  given  infection 
will  produce  a  secondary  disturb- 
ance of  nutrition  more  readily 
in  children  fed  upon  those  diets 
which  tend  to  produce  dyspepsia 
(e.  g,,  milk  dilutions  with  carbo- 
hydrate additions,  or  buttermilk 
mixtures  rich  in  carbohydrates), 
than  in  those  fed  with  mother 's 
milk  or  protein-milk.  The  con- 
ception of  a  relationship  between 
infections  and  disturbances  of 
nutrition  has  been  already 
reviewed. 

Symptoms. — The  symptoms 
of  mild  secondary  disturbances 
of  nutrition  resemble  those  of 
dyspepsia;  that  is,  besides  the 
signs  of  infection,  dyspeptic 
stools  occur,  which  may  be  im- 
proved by  changes  in  diet  while 
the  fever  continues.  In  contrast 
to  simple  inanition  we  have  a 
marked  and  sudden  loss  of 
weight  even  when  a  fairly  large 
quantity  of  food  is  being  taken. 
This  indicates  a  severe  disturb- 
ance of  nutrition,  the  character 
of  which  gradually  comes  to 
resemble  more  and  more  closely 
alimentary  intoxication.  The 
threatening  loss  of  weight  may 
be  overcome,  in  many  cases,  by 
the  same  methods  employed  in 
a  primary  alimentary  intox- 
ication. The  manifestations 
characteristic  of  the  infection, 
however,  remain.  It  is  quite 
certain  that  a  large  percentage 
of  cases  running  a  severe  toxemic 
course  and  formerly  classified 
as  general  septic  intoxications, 
were,  in  fact,  no  more  than  com- 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


301 


plications  of  a  severe  secondary  intoxication  which  could  have  been  cured 
by  dietetic  therapy. 

The  combination  of  infection  and  disturbance  of  nutrition,  that  is  of 


Week. 


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FIG.  90. — Severe  secondary  disturbance  of  'nutrition  resembling  intoxication  occurring  as  the  result  of 
vaccination.    Recovery  on  diet  of  protein-milk.     +  =  pathologic  stools;    I   =  normal  stools. 

alimentary  fever  and  alimentary  intoxication,  produces  many  interesting 
complications.  For  instance,  a  fever  may  be  partially  due  to  infection  and 
in  part  to  alimentary  causes;  and  the  necessary  changes  in  diet  will  then 
cause  a  lowering  of  the  fever  by  eliminating  the  alimentary  factor,  so  that 


302  TEXT-BOOK  OF  PEDIATRICS 

the  hyperpyretic  course  becomes  moderately  febrile.  Or,  that  which  starts 
as  an  infective  fever  may  lapse  into  an  alimentary  fever,  without  recogni- 
tion of  the  change,  since  the  infection  has  been  overcome  while  the  added 
secondary  disturbance  of  nutrition  sustains  the  fever,  which  yields  only  to 
a  reduction  of  the  food  supply.  Finally,  the  child  may  be  so  severely 
injured  by  the  infection  that  the  existing  toxic  condition  is  maintained, 
even  in  starvation,  by  an  autotoxicosis. 

After  successfully  combating  an  infection,  many  children,  easily  nour- 
ished before  the  infection,  remain  in  a  state  of  exhaustion  which  is  exactly 
like  the  condition  produced  by  a  primary  transgression  of  the  limits  of 
tolerance.  The  post-infective  disturbances  of  nutrition,  therefore,  resemble 
in  their  symptoms  and  their  reaction  to  food  the  picture  of  dystrophy, 
dyspepsia  or  decomposition. 

Diagnosis. — The  most  important  symptom  of  a  secondary  disturbance 
of  nutrition,  aside  from  the  diarrhoea,  the  significance  of  which  is  not  always 
clear,  is  the  continuous  loss  of  weight.  If  an  infected  child  continues  to 
lose  weight  rapidly,  the  cause  must  be  a  disturbance  of  nutrition,  unless, 
indeed,  the  child  absolutely  refuses  food.  The  loss  due  to  slight  underfeeding 
would  cease  in  several  days,  or  would  be  gradual.  The  reaction  to  the  with- 
drawal of  food  or  to  other  changes  in  diet  would  in  itself  show  what  symptoms, 
dependent  upon  the  dietetic  influence,  could  be  considered  alimentary. 

Treatment. — With  young  infants  the  hope  of  overcoming  an  infection, 
and  especially  one  complicated  by  disturbances  of  nutrition,  is  much 
greater  if  the  child  is  fed  at  the  breast  than  it  is  with  the  customary  methods 
of  artificial  feeding,  so  that  one  must  urge  the  use  of  breast-milk  if  it  may 
possibly  be  obtained.  Recent  experiences  have  taught  us  that  quite  suc- 
cessful results  may  be  obtained  by  the  use  of  protein-milk  (with  a  3  to  7  per 
cent,  addition  of  sugar).  Under  no  circumstance,  should  the  child  be 
reduced  to  a  state  of  inanition.  Even  with  the  most  satisfactory  diet,  to 
say  nothing  of  the  rather  generally  used  flour  food,  the  patient  is  seriously 
handicapped  by  an  insufficiency  of  food.  As  soon  as  loss  of  weight  ceases, 
or  even  when  the  loss  is  slight,  the  food  may  be  increased  and  should  always 
be  sufficient  to  allow  an  excess  over  the  absolute  necessity  of  repair.  Only 
when  a  sudden  fall  in  weight  occurs  and  toxic  symptoms  appear  should  the 
food  be  discontinued  for  a  half -day  and  then  resumed  in  small  quantities,  as 
indicated  in  pure  alimentary  intoxication.  In  using  protein-milk,  a  reduc- 
tion of  the  carbohydrate  content  below  three  per  cent,  should  be  avoided. 
When  the  poison  is  not  entirely  eliminated  by  these  methods,  the  food 
quantity  must  be  increased  in  the  same  manner  as  heretofore  advised.  By 
this  means,  many  children  are  saved  who  would  certainly  be  lost  under  a 
starvation  method.  Diarrhoea  alone  is  not  sufficient  reason  for  reducing 
the  quantity  in  either  form  of  feeding. 

If  the  child  is  taking  other  forms  of  food  at  the  outset  of  its  sickness, 
and  especially  within  the  first  three  months  of  life,  the  change  to  breast-milk 
or  protein-milk  is  to  be  recommended.  If  this  is  not  possible,  starvation  is 
still  to  be  avoided.  If  we  are  forced  to  reduce  the  quantity  of  food  because 
of  severe  diarrhoea,  sudden  loss  of  weight,  or  symptoms  of  intoxication,  the 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  303 

case  is  extreme  and  the  prognosis  very  questionable;  at  least  among  very 
young  children  but  a  few  can  be  saved  without  the  change  of  food.  Of 
course,  children  suffering  with  infections  may  recover  successfully  with  other 
food  mixtures,  but  the  percentage  of  unfavorable  cases  in  very  young 
infants  is,  other  things  being  equal,  considerably  reduced  with  either  the 
natural  food  or  protein-milk. 

THE  DISTURBANCES  OF  NUTRITION  OF  BREAST-FED  INFANTS 

With  the  exception  of  actual  underfeeding,  the  most  important  form  of 
disturbance  of  nutrition  of  the  breast-fed  child  is  indicated  by  diarrhoea, 
with  a  "dyspeptic"  condition  of  the  stool.  We  should  guard  against  making 
a  diagnosis  of  a  disturbance  of  nutrition  upon  the  least  variation  of  the 
bowel  movement  from  the  usual  picture  of  the  normal  breast-milk  stool, 
which  is  of  a  golden  yellow  and  an  inoffensive  odor.  Many  children  fed  at 
the  breast  have  occasionally  or  continuously  green,  thin,  slimy  evacuations 
containing  fat  flakes,  incorrectly  called  "  curds, "  which  may  be  increased  in 
number  or  otherwise  changed  without  any  special  effect  upon  the  general 
well-being.  The  causes  and  conditions  which  bring  about  such  a  changed 
consistency  of  the  stools  have  not  been  wholly  explained,  but  in  no  case  do 
such  stools  justify  the  intervention  by  the  physician  and  certainly  not  a 
departure  from  the  method  of  feeding,  either  in  a  change  of  wet-nurse,  a 
reduction  of  quantity,  or,  least  of  all,  weaning.  The  child  is  to  be  considered 
diseased  only  when,  besides  seemingly  abnormal  evacuations,  other  certain 
signs  of  disturbance  of  development  and  of  general  well-being  are  found. 

A  distinction  must  be  drawn  between  the  exogenous  diseases,  i.  e., 
diseases  due  to  causes  extrinsic  to  the  child  itself,  such  as  excessive  feeding, 
improper  composition  of  the  food,  heat,  or  intercurrent  infection — and  the 
endogenous  diseases,  due  to  the  constitutional  peculiarities  of  the  child  which 
cause  a  pathologic  reaction  to  mother's  milk.  The  former  may  be  recog- 
nized clinically  by  the  fact  that  they  always  occur  more  or  less  acutely  after 
a  period  of  normal  development,  while  the  latter  appear  immediately  after 
birth  and  are  chronic.  It  goes  without  saying  that  a  disease  of  the  first 
category  may  occur  during  the  first  few  days  of  life. 

Etiology. — The  diseases  due  to  improper  composition  of  the  milk  play  a 
large  part  as  representatives  of  the  first  group.  Formerly  it  was  supposed 
that  the  milk  of  certain  women  could  not  be  safely  taken  by  infants.  In 
other  cases,  the  breast-milk  was  thought  to  be  so  affected  by  passing  dis- 
turbances in  the  condition  of  the  nursing  mother,  such  as  acute  and  chronic 
diseases,  errors  of  diet,  menstruation,  psychic  irritation,  and  even  substances 
directly  transmitted  from  the  mother's  food,  as  to  do  serious  injury  to  the 
child.  These  beliefs,  as  a  whole,  must  be  classed  as  superstitions.  Only  in 
the  event  of  menstruation  or  of  intercurrent  pregnancy  is  it  possible  that 
vomiting,  restlessness,  dyspeptic  stools,  may  occasionally  occur;  but  even 
then  with  but  a  small  number  of  children.  These  disturbances  are  under  no 
circumstances  so  serious  as  to  warrant  interference  with,  or  change  in  diet, 
unless,  of  course,  the  breast  ceases  to  functionate. 


304  TEXT-BOOK  OF  PEDIATRICS 

Of  far  greater  importance,  as  causes  of  the  injuries  belonging  in  this 
category,  are  overheating,  exposure  to  cold,  neglect  and,  especially,  infec- 
tions. The  parenteral  infections,  occurring  with  enteral  or  gastro-intestinal 
symptoms  (coryza,  la  grippe;  cystitis,  stomatitis,  etc.),  may  develop  with 
such  clear  evidences  that  a  diagnosis  is  readily  made.  Very  frequently 
their  course  is  so  mild  that,  aside  from  the  dyspeptic  manifestations,  only 
the  most  careful  observation,  as  may  hardly  be  had  in  the  home,  will  give  a 
good  understanding  of  the  conditions.  Such  cases  are  diagnosed  incorrectly 
as  the  result  of  the  harmful  action  of  the  breast-milk. 

Overfeeding  is  another  cause  of  dyspepsia.  It  seldom  occurs  with 
regular  and  infrequent  nursing,  but  rather  when  the  nourishment  is  irregu- 
larly given  and  at  frequent  intervals.  The  total  quantity  of  the  food  is 
probably  none  too  great  in  these  cases. 

Finally,  hunger,  that  is,  underfeeding,  and  probably  only  in  certain 
individuals  peculiarly  susceptible,  may  bring  about  the  symptom-complex 
of  dyspepsia. 

The  symptoms  of  a  disturbance  of  nutrition  in  the  breast-fed  child  are 
practically  the  same  as  those  of  dyspepsia  in  the  bottle-fed.  Severe  condi- 
tions are  much  more  infrequent  than  in  children  under  artificial  feeding; 
but  they  do  occur,  sometimes  with  the  picture  of  decomposition  and  more 
frequently  in  a  transitional  form  between  dyspepsia  and  intoxication ;  that 
is,  with  fever,  apathy,  lactosuria,  etc.  It  is  very  improbable,  however,  that 
in  these  serious  cases  the  food  alone  has  had  an  unfavorable  influence.  They 
would  rather  appear  in  the  first  instance  to  be  due  to  unskilful  attempts  at 
therapeutic  starvation,  and,  second,  to  be  incident  to  added  infection. 

Diagnosis. — The  diagnosis  of  the  dyspepsia  of  the  overfed  is  made  by 
the  history  and  by  determining  the  excessive  quantity  of  milk.  In  other 
forms,  it  must  be  made  by  a  careful  observation  of  the  environment  as  well 
as  of  the  symptoms  and  the  course  of  the  disease. 

Treatment. — Interference  in  the  latter  conditions  is  generally  not  only 
unnecessary,  but  strongly  contraindicated.  It  is  better  to  encourage  the 
mother  and  to  wait  patiently  until  recovery  takes  place  spontaneously. 
But  with  the  dyspepsia  of  overfeeding,  treatment  must  be  more  active. 
Stringent  rules  of  nursing  are  necessary  and,  in  severe  cases,  at  times  a 
marked  reduction  of  the  food  quantity  is  required.  If  the  child,  being  used 
to  a  large  quantity  of  food,  becomes  restless,  tea  with  benzosulphinidum, 
(saccharin),  may  be  given;  or,  if  necessary,  during  the  first  few  days,  a  mild 
sedative,  such  as  sodium  diethylbarbiturate  (medinal),  chloral  hydrate 
one  teaspoonful  of  a  one  per  cent,  solution,  two  or  three  times  a  day  or,  in  two 
per  cent,  solution,  one  teaspoonful,  every  two  or  three  hours.  Dyspepsia 
due  to  hunger  recovers  on  the  contrary,  if  sufficient  food  is  given.  In  cases 
of  other  etiology,  it  is  usually  advisable  to  wait.  Only  when  severe  loss  of 
weight  occurs  and  slight  somnolence,  cyanosis  and  other  indications  of  a 
more  severe  condition  appear,  is  it  necessary  to  give  the  breast-fed  child  a 
short  hunger  period  and  then  to  increase  the  food  quantity  gradually,  as  in 
the  case  of  the  artificiallv-fed  babe. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  305 

DISEASES  DUE  TO  ENDOGENOUS  (CONSTITUTIONAL)  CAUSES 

Symptoms. — Children  are  occasionally  seen  who,  from  birth,  do  not 
develop  well  with  breast  feeding.  In  severe  cases,  there  may  be  loss  of 
weight,  due  to  the  lack  of  appetite,  and  with  this  distinct  and  frequently 
marked  signs  of  dyspepsia.  In  typical  instances,  there  is  anorexia,  severe 
flatulence,  attacks  of  colic,  frequent  eructations,  hiccough  and  regurgitation 
and  withal  a  great  general  restlessness  and  emaciation.  The  stools  fre- 
quently show  the  characteristics  of  a  fat  diarrhoea.  By  a  combination  of 
all  these  signs  with  eczematous  and  intertriginous  changes,  serious  disease- 
pictures  may  arise.  With  many  of  these  children,  other  signs  are  found 
which  are  indicative  of  a  neurotic  diathesis,  such  as :  loss  of  muscle  tone  or 
hypertonicity,  ptotic  manifestations  (diastasis  of  the  recti,  floating  tenth 
rib,  visceral  ptotic,  hernias,  etc.),  a  tendency  to  be  readily  frightened,  an 
increased  muscular  irritability,  vasomotor  pallor,  etc.  Furthermore,  the 
history  may  reveal  hereditary  nervous  stigmata. 

Etiology. — Formerly  there  was  a  tendency  to  blame  the  unfit  composi- 
tion of  the  breast-milk  for  the  disease-picture  we  have  described :  that  is,  the 
milk  was  supposed  to  be  too  rich.  While  it  must  be  admitted  that  in 
exceptional  cases  improvement  is  had  by  a  change  of  wet-nurses,  it  is  the 
common  rule  that  such  children  do  not  develop  properly  with  any  breast- 
milk.  Considering,  moreover,  that  the  very  food  which  is  of  so  little  advan- 
tage in  these  cases  is  satisfactory  for  other  children,  it  is  clear  that  not  the 
food  is  to  be  blamed,  but  rather  the  constitutional  peculiarity  of  the  child 
which  causes  the  paradoxical  response  to  natural  feeding.  In  fact,  we  have 
to  do,  on  the  one  hand,  with  neuropathic  individuals;  and,  on  the  other 
hand,  with  representatives  of  that  anomalous  constitutional  quality 
which,  at  present,  we  prefer  to  designate  as  an  exudative  diathesis.  Both 
of  these  conditions  may  appear  separately  or  together.  No  clear  conception 
of  the  relation  between  the  constitutional  disturbance  and  the  symptoms 
referable  to  the  digestive  apparatus  has  yet  been  formed. 

Treatment. — In  the  treatment  of  these  disturbances,  the  customary 
change  of  wet-nurses  is  not  to  be  recommended.  Only  rarely  is  it  possible 
to  find  a  wet-nurse  whose  milk  will  be  better  for  the  child  than  its  mother 's 
and  very  probably  the  expected  result  will  not  be  obtained  by  even  a  num- 
ber of  changes.  An  especial  warning  must  be  given  against  the  attempt  to 
treat  dyspeptic  symptoms  in  these  cases  with  starvation.  Hunger  never 
does  any  good  and  is  always  harmful.  On  the  other  hand,  we  may  resort  to 
satisfactory  measures,  the  action  of  which  is  not  to  be  entirely  explained, 
in  the  way  of  additions  to  the  human  milk  of  protein  preparations,  or  in 
the  complemental  feeding  of  cow's  milk.  One  dram  of  calcium  casein- 
ate  in  one  ounce  of  mineral  water,  may  be  given  three  to  five  times  a 
day  from  the  bottle,  or  with  a  spoon.  Of  the  cow's  milk  mixtures,  the 
buttermilk  mixture  gives  the  best  results.  In  mild  cases,  the  addition  of 
one  meal  may  be  sufficient,  while  in  more  severe,  two  or  three  may  be 
necessary  with  a  corresponding  reduction  in  the  quantity  of  breast -milk. 
The  results  of  both  of  these  methods,  in  the  increase  of  weight  and  of  appe- 
20 


306 


TEXT-BOOK  OF  PEDIATRICS 


tite  and  in  the  improvement  of  the  general  condition  are  almost  always 
astonishing  (Fig.  91).  In  many  cases,  however,  the  stools  remain  slightly 
dyspeptic  for  a  long  time. 

Idiosyncrasies. — Occasionally  a  dyspepsia,  due  to  constitutional  causes, 
reaches  such  a  grade  of  severity  that  we  may  speak  of  an  idiosyncrasy  to 
breast-milk.  The  patient  may  even  die  despite  of  mixed  feeding  or  weaning. 
This  may,  of  course,  be  considered  as  the  result  of  a  long  continued  inanition 
due  to  the  spontaneously  inadequate  nursing,  or  to  the  misdirected  attempts 
at  remedy  on  the  part  of  the  physician.  Another  rare  form  of  idiosyncrasy 
to  breast-milk  is  seen  in  the  fainting  spells  which  occur  from  birth  at  every 
nursing,  or  at  least  several  times  a  day,  and  which  disappear  after  weaning. 
It  is  not  certain  whether  the  composition  of  the  breast-milk  itself  produces 


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FIG.  91. — Recovery  from  severe  endogenous  constitutional  dyspepsia  by  the  use  of  breast-milk 
with  addition  of  dextrin  and  maltose  and  mineral  water. 

the  injury  in  these  cases  or,  as  seems  more  probable,  that  the  exertion  of 
sucking,  incident  to  an  abnormal  vasomotor  irritability,  is  at  fault. 

The  idiosyncrasy  of  some  breast-fed  children  to  cow's  milk  is  also  of 
importance.  These  children,  having  acquired  a  disturbance  of  nutrition 
under  artificial  feeding,  when  given  breast-milk  develop  satisfactorily,  but 
when  the  attempt  at  weaning  is  again  made  respond  to  the  first  addition  of 
cow's  milk  with  an  abnormal  reaction.  This  has  been  observed  in  mixed 
feeding  with  doses  of  cow's  milk  as  small  as  5  c.c.  or  less.  The  symptoms 
vary  according  to  the  doses  and  the  sensibility  of  the  child.  In  mild  cases, 
they  resemble  a  slight  dyspepsia,  with  fever,  which  appears  a  few  hours  after 
the  cow's  milk  has  been  given;  in  severer  cases,  the  complete  picture  of  an 
intoxication,  with  even  a  fatal  ending,  may  be  produced. 

Such  children  must  be  fed  at  the  breast  for  a  long  time  until  they  gradu- 
ally lose  their  sensitivity.  Sometimes  it  is  possible  to  develop  a  tolerance  by 
increasing  the  quantity  of  cow's  milk  drop  by  drop.  Severe  toxic  reactions 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  307 

must  be  treated  by  prompt  withdrawal  of  the  food  and,  later,  by  such  care- 
ful feeding  as  in  intoxication;  for  even  though  the  cow's  milk  be  wholly 
discontinued  and  the  child  be  permitted  to  take  as  much  mother's  milk  as 
it  wants,  an  unfavorable  result  may  be  unavoidable. 

DISTURBANCES  OF  NUTRITION  OF  OLDER  CHILDREN 

After  the  first  year  of  life,  more  particularly  after  the  second  year,  the 
constitution  of  the  child  is,  as  a  rule,  so  firmly  established  that  the  severe 
disturbances  of  nutrition  which  so  frequently  develop  in  the  nursling  are 
hardly  ever  encountered.  Its  disturbances  are  usually  classified  as  acute  or 
chronic  dyspepsias.  They  correspond  in  fact,  to  those  conditions  which 
have  been  described  above  for  dyspeptic  infants  within  narrower  lines,  in 
that  their  symptoms  are  entirely  those  of  local  fermentation  and  irritation, 
while  the  general  well-being  and  the  metabolism  at  large  are  not  altered  in 
any  noticeably  severe  degree.  Nevertheless,  occasionally,  even  in  older 
children,  symptoms  appear  which  in  their  form  and  mode  of  onset  are 
distinctly  those  of  alimentary  fever  and  alimentary  intoxication  (see  acute 
dyspepsia);  and,  similarly,  chronic  (disturbances  develop  of  so  severe  a 
nature  that  they  fit  completely  into  the  picture  of  decomposition  (compare 
chronic  digestive  insufficiency).  The  probability  of  a  pathogenetic  identity, 
with  slight  variations  between  the  disturbances  of  nutrition  in  these  older 
and  younger  children,  is  the  more  readily  conceivable  when  we  consider 
that  in  both  the  same  therapeutic  principles  give  identical  results. 

ACUTE  DYSPEPSIA  AND  DYSPEPTIC  COMA 

Symptoms. — Acute  dyspepsia  has  a  sudden  onset  and  is  initiated  by 
headache,  loss  of  appetite  and  malaise,  with  nausea,  vomiting,  and  fever  and 
frequently,  marked  prostration.  The  tongue  is  coated,  there  is  strong  fetor 
from  the  mouth,  frequently  a  distinctly  acetone  odor,  slight  distention  of  the 
abdomen,  constipation  and  often,  later,  diarrhoea.  The  pulse  is  rapid  and 
may  also  be  variable,  or  occasionally  slow  and  irregular.  Albumin  and  casts 
are  usually  found  in  the  urine. 

With  proper  treatment  this  condition  does  not  last  long;  convales- 
cence may  set  in  after  two  or  three  days,  or  even  less.  In  other  cases, 
it  may  drag  on  for  a  longer  time  and  a  condition  which  may  be  called 
"status  gastricus"  develops. 

In  a  considerable  number  of  cases,  other  symptoms  are  associated  with 
those  enumerated  which  make  the  disease-picture  more  impressive.  These 
symptoms  in  their  variety  and  intensity  are  those  recognized  in  the  intoxi- 
cation of  infants,  and,  when  sufficiently  developed,  produce  dyspeptic 
coma.  Before  the  disturbance  of  consciousness  goes  on  to  coma,  symptoms 
of  spinal  and  cerebral  irritation  may  appear,  occasionally  severe  convulsions 
continuing  for  hours;  deep  respiration  is  observed,  and  sugar,  or  at  least 
strongly  reducing  substances,  may  occur  in  the  urine.  The  acetone  odor  is 
especially  strong  and  unusually  large  amounts  of  acetone  can  be  demon- 
strated in  the  urine. 

The  prompt  results  which  follow  in  one  or  two  days  after  emptying  the 


308  TEXT-BOOK  OF  PEDIATRICS 

intestine,  show  that  the  cause  of  these  symptoms,  as  of  simple  dyspepsia,  is 
an  intoxication  arising  in  the  digestive  tract.  Nothing  further  is  known 
about  the  poison.  It  is  very  doubtful  however  whether  we  have  to  deal  with 
acetone  poisoning,  as  was  formerly  believed.  The  clinical  resemblance, 
also,  to  intoxication  in  the  infant  indicates  that  similar  conditions  are 
causative.  A  dietetic  error,  an  overloading  of  the  stomach  or  some  similar 
circumstance  is  usually  the  .cause  of  the  dyspepsia;  but  frequently  such  a 
cause  cannot  be  established.  Then,  doubtless,  an  infection  of  some  kind 
has  given  rise  to  the  appearance  of  secondary  alimentary  disturbance,  the 
symptoms  of  which  still  remain  after  the  removal  of  the  signs  of  dyspepsia. 
This  frequently  occurs  in  the  course  of  influenza. 

The  diagnosis  is  not  always  easy  at  the  beginning.  Typhoid  and 
paratyphoid,  meningitis  and  similar  conditions  may  come  up  for  consider- 
ation. Many  disturbances  diagnosed  as  dyspepsia  are  certainly  nothing 
more  than  an  infection  exhibiting  gastro-intestinal  symptoms.  The  surest 
differentiation  is  given  by  the  prompt  results  of  a  thorough  empt3dng  of  the 
stomach  and  intestine,  after  which  any  disturbance  that  can  be  classified 
as  dyspepsia  must  disappear;  if  symptoms  remain,  it  is  certainly  not  pri- 
mary dyspepsia,  but  only  dyspepsia  accompanying  some  other  disease. 

The  treatment  consists  in  the  removal  of  the  gastro-intestinal  con- 
tents as  rapidly  as  possible.  Calomel  0.05-0.1  gm.  (1-2  grs.),  repeated  two 
or  three  times;  castor  oil,  rhubarb,  etc.,  are  used  forncatharsis;  enteroclysis, 
or  glycerin  enemata  are  useful.  Occasionally  gastric  lavage  may  be  em- 
ployed. Emetics,  such  as  syr.  ipecac  4  c.c.  (1  dram),  wine  of  antimony  a 
teaspoonful,  are  not  of  much  use.  This  treatment  should  be  followed  by  a 
liquid  diet;  for  several  days  small  amounts  of  food  should  be  given  and 
finally  a  tonic. 

An  "asthmatic  dyspepsia"  must  also  be  described.  This  is  a  condition 
which  begins  suddenly  with  dyspnoea,  lasting  for  hours  or  days,  and  is 
relieved  by  emptying  the  intestinal  tract.  How  much  of  the  effect  is 
mechanical  and  due  to  meteorism,  or  the  high  position  of  the  diaphragm, 
and  how  much  is  due  to  reflex  action  and  intoxication  imposed  upon  a  ner- 
vous constitution  is  not  clear. 

CHRONIC  DYSPEPSIA 

(Chronic  gastro-intestinal  catarrh,  chronic  intestinal  and  colonic 
catarrh.) 

In  the  majority  of  cases,  chronic  dyspepsia  develops  from  an  acute 
intestinal  disturbance,  usually  of  infective  origin  which  may  be  either 
enteral  or  parenteral.  A  primary  acute  dyspepsia  is  less  frequently  causa- 
tive. In  certain  patients  the  onset  is  very  gradual  and  neither  the  period  of 
incidence  nor  any  external  influence  is  recognized.  In  these  cases,  constitu- 
tional faults  are  of  probable  importance,  since  there  are  no  dietetic  errors  to 
explain  the  congenital  or  even  the  familial disabilityof  the  digestivefunctions. 

The  greater  number  of  cases  occur  during  the  second  to  the  fourth 
year.  At  later  age  disorders  of  this  class  are  more  infrequent.  Many 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  309 

chronic  intestinal  disturbances  of  older  children  have  their  beginning,  how- 
ever, in  infancy.  Various  forms  of  chronic  dyspepsia  are  seen. 

Chronic  dyspepsia  of  gastric  origin  is  infrequent  compared  with  other 
forms.  It  occurs  in  lean,  pale,  capricious,  morose  children  where  the  one 
symptom  indicative  of  gastric  disorder  is  a  marked  anorexia.  To  this  may 
be  added  occasional  eructation  and  vomiting  and  sometimes  the  abdomen  is 
distended  in  its  upper  portion.  With  the  test-meal,  we  find  abnormal 
chronic  conditions  in  the  way  of  a  slight  catarrh  and  a  particularly  marked 
motor  insufficiency  of  the  stomach  which,  in  severer  cases,  is  combined  with 
atony  or  even  gastro-paresis. 

Gastro-paresis  is  a  condition  of  hypotonicity,  in  consequence  of  which 
distention  of  the  stomach  becomes  abnormally  great  even  with  moderate 
amounts  of  food.  The  most  extreme  degree  is  atony  or  atonic  dilatation, 
in  which  the  stomach  cannot  regain  its  normal  size  even  when  empty.  It 
contrasts  with  the  mechanical  distention  of  organic  stenosis  in  that  it 
exhibits  no  anatomic  changes  in  the  gastric  walls.  Mild  degrees  of  gastro- 
paresis  are  frequently  found  in  cases  of  general  debility  and  improve  when 
this  is  removed.  Only  those  cases  are  of  importance  to  the  physician  in 
which  the  insufficiency  of  the  organ  is  so  great  as  to  be  the  chief  cause  of 
existing  symptoms. 

Constipation  is  common,  although  gastric  fermentation  may  produce 
intestinal  irritation  and  chronic  diarrhoea.  This  must  always  be  considered 
as  gastric  in  its  origin. 

Severe  grades  of  the  disease  may  lead  to  marked  exhaustion  and  may 
even  result  in  death.  With  careful  treatment,  the  prognosis  of  even  the 
more  advanced  cases  is  quite  favorable.  A  considerable  time  may  elapse, 
however,  before  complete  recovery  results.  In  its  diagnosis,  nervous  ano- 
rexia must  be  considered.  Usually  it  may  be  differentiated  without  the  use 
of  the  stomach-tube,  since  children  with  nervous  anorexia  are  lively  and  the 
appetite  for  some  kinds  of  food  is  good.  With  existing  diarrhoea,  the  differ- 
entiation from  other  forms  of  dyspepsia  must  be  made  with  the  stomach- tube. 

In  the  common  form  of  chronic  dyspepsia  disturbance  of  the  gastric 
function  is  not  so  prominent  a  symptom.  In  the  disease-picture  the  intes- 
tinal symptoms,  and  especially  diarrhoea,  overshadow  all  others.  Lancinat- 
ing and  colicky  pains  may  occur.  The  appetite  is  variable ;  it  may  even  be 
good.  The  evacuations  are  commonly  not  very  numerous  and  contain 
more  or  less  mucus.  The  stools  present  variable  special  findings.  Their 
reaction  may  be  either  acid  or  alkaline.  Undigested  food  particles  may  con- 
sist of  fat,  starch  and  vegetable  shreds.  Connective  tissue  shreds  are  found 
only  after  the  ingestion  of  raw  or  partially  cooked  meats;  muscle  fibres  are 
rarely  seen.  Foamy  fermentation  is  present — a  fermentation  so  intense  that 
it  continues  after  the  evacuation  of  the  discharges.  The  general  health  is 
affected  in  proportion  to  the  difficulty  of  feeding;  nutrition  is  more  or  less 
unsatisfactory.  Mild  anemia  is  common  and,  in  younger  children,  rickets. 
The  majority  of  cases  show  symptoms  of  nervous  irritability  and  in  infants 
latent  spasmophilia  is  common. 


310  TEXT-BOOK  OF  PEDIATRICS 

The  repeated  occurrence  of  exacerbation  is  very  characteristic  of  this 
disease.  An  aggravation  may  be  brought  on  by  other  intercurrent  diseases 
(respiratory  catarrh,  etc.),  or  by  overfeeding  or  improper  food.  A  repeti- 
tional  attack  may  be  accompanied  by  severe  diarrhoea  with  blood  and 
mucus,  accompanied  by  fever,  with  serious  impairment  of  the  general 
health.  Even  choreiform  or  typical  attacks  of  tetany  may  occur.  Many 
undigested  particles,  or  even  larger  masses  of  food  which  have  not  properly 
been  broken  up,  may  be  found  in  the  stools  at  this  time. 

Of  the  cases  belonging  to  this  group,  quite  a  large  number  are  in  the 
nature  of  fermentation  dyspepsia,  due  to  imperfect  digestion  of  carbohy- 
drates (A.  Schmidt).  In  these,  the  evacuations  are  thin  or  pasty,  of  varying 
consistency,  containing  variable  amounts  of  mucus;  they  are  light  in  color 
and  filled  with  bubbles.  i  Their  reaction  is  acid  and  the  odor,  sour.  The  iodine 
test  gives  a  strong  starch  reaction.  Microscopically,  one  may  discover, 
besides  the  starch  cells,  many  iodophilic  bacteria.  Careful  chemical  analysis 
shows  that,  on  the  average,  the  carbohydrate  content  of  the  feces  is  more  than 
doubled.  In  the  saccharimeter,  fermentation  occurs  after  twenty-four  hours. 

Typical  cases  of  this  kind  can  be  readily  diagnosed;  indeterminate  forms 
in  which  the  consistency  of  the  stools  is  not  so  characteristic  are  probably 
more  common.  In  these,  one  may  have  stools  of  darker  color,  of  changing 
reaction,  with  no  response  to  the  starch  test.  In  spite  of  these  findings,  it 
must  be  remembered,  in  seeking  proper  therapeutic  measures,  that  some 
carbohydrate  is  the  initial  cause  of  the  fermentation  dyspepsia.  While  the 
carbohydrate  may  have  been  so  well  digested  that  no  free  starch  is  found  in 
the  colon,  we  may  still  have  acid  formation.  The  acid  reaction  may  be  neu- 
tralized by  the  secretion  of  the  large  quantities  of  the  alkaline  intestinal  fluids. 

It  is  probably  true  of  older  children,  as  well  as  of  infants,  that  a  disturb- 
ance of  carbohydrate  digestion  is  the  primary  cause  of  dyspepsia;  that  the 
disturbance  of  fat  and  protein  digestion  is  secondary  to  the  amylolytic  and 
glycolytic  failure,  and  that  the  absorptive  and  peristaltic  failure  are  caused 
by  the  acids  of  carbohydrate  fermentation.  The  supposition  that  a 
primary  fat  or  protein  digestive  disturbance  is  the  basis  of  this  lienteric 
condition  is,  in  general,  unjustified. 

Mucous  Colitis. — Only  in  one  special  form  of  disease  which  should  be 
classed  not  as  a  dyspepsia,  but  rather  as  a  catarrh  due  to  local  irritation, 
does  the  protein  digestion  play  a  particular  role.  This  is  mucous  colitis. 
This  disease,  which  runs  its  course  without  important  suggestive  symptoms, 
is  characterized  by  the  passage  of  large  quantities  of  mucus,  at  times 
jesembling  casts  of  the  intestine  and  again  covering  the  fecal  masses.  In 
this  condition,  children  have  usually  been  fed  large  quantities  of  meat  and 
eggs,  while  the  vegetables  and  carbohydrates  of  the  diet  have  been  reduced. 
The  constipation  thus  produced  is  usually  the  cause  of  the  catarrh  of  the 
colon  which  results  in  this  excessive  mucoid  secretion.  Mucous  colitis  must 
not  be  mistaken  for  membranous  enteritis  or  mucous  colic,  a  condition  in 
which  long  white  shreds  and  tubular  casts  of  the  intestinal  tube  are  passed 
under  extremely  severe  pain.  These  shreds  and  casts  consist  of  mucin;  the 


DISEASES  O*   THE  DIGESTIVE  SYSTEM  311 

disease  involves  no  inflammation  of  the  mucous  membrane.  Their  evacua- 
tion occurs  at  intervals  of  weeks  or  months.  The  disorder  is  probably  in  the 
nature  of  a  secretory  neurosis. 


Those  not  infrequent  cases  which  are  termed  severe  chronic  digestive 
insufficiency  in  older  children  must  be  regarded  as  chronic  dyspepsia  in  its 
most  severe  forms.  Children  affected  with  this  condition  usually  come  from 
families  with  a  severe  neuropathic  taint  and  often  show  neuropathic  symp- 
toms themselves.  While  some  of  them  have  passed  infancy  without  notice- 
able disturbances;  others  have  shown,  even  at  this  time,  lowered  resistance, 
and  digestive  failure.  The  actual  disease  begins  insidiously  or  as  a  sequel 
to  acute  dyspepsia  or  to  an  infection.  Its  chief  characteristic  is  the  marked 
liability  to  digestive  disturbances.  Slight  dietetic  errors,  or  unimportant 
infections  promptly  produce  intestinal  symptoms  severe  in  themselves  and 
of  severe  effect  upon  the  general  well-being.  It  is  not  uncommon  to  see  a 
loss  of  several  pounds  in  weight  within  a  few  days  in  connection  with  a 
slight  coryza,  a  vaccination,  or  following  the  ingestion  of  some  unaccus- 
tomed food.  Extreme  weakness  and  debility  are  cause  for  anxiety.  A 
choleric  alimentary  intoxication  with  all  its  typical  symptoms  may  develop. 
A  second  characteristic  peculiarity  is  the  stunted  growth  and  retarded  gain 
in  weight.  The  occurrence  of  long  periods  with  no  gain  in  weight,  even 
though  there  is  no  intercurrent  disease,  show  how  greatly  the  growth  suffers. 
Children  of  four  years,  but  with  the  weight  of  a  twelve  months  old  infant 
and  with  size  corresponding  to  weight  are  not  uncommon;  so  that  we  may  be 
justified,  to  a  certain  extent,  in  speaking  of  this  as  a  type  of  infantilism.  A 
third  characteristic  may  be  mentioned  in  the  abnormally  reduced  capacity 
for  repair. 

While  it  is  possible  in  ordinary  forms  of  dyspepsia  to  restore  the  intes- 
tine to  normal  functional  ability  after  several  weeks  of  careful  dieting,  in 
these  severe  forms  a  sensitivity  remains,  even  after  the  bowel  movements 
have  been  normal  for  a  long  time.  A  slight  change  in,  or  increase  of  diet 
may  immediately  cause  an  aggravation  of  the  disease. 

The  number  of  evacuations,  excepting  during  these  times  of  intercur- 
rent aggravation,  is  normal  or  but  slightly  increased.  The  massiveness  of 
the  stool  is  especially  noticeable;  it  may  weigh  a  pound  or  more;  the  reaction 
is  usually  acid  and  there  is  a  strong  tendency  to  fermentation,  which  fre- 
quently continues  after  evacuation.  The  food  substances  are  poorly 
digested;  that  is,  large  percentages  of  fat  and,  in  severe  cases,  of  the  starches 
also,  are  excreted.  The  protein  digestion,  on  the  contrary,  is  not  noticeably 
reduced,  excepting  at  the  time  of  acute  aggravation,  when  large  amounts  of 
undigested  meat  shreds  are  found  in  the  stool.  Protein  digestion  is  also 
unfavorably  affected  in  those  children  in  whom  the  test-meal  shows  an  exist- 
ing achylia. 

The  nutritional  condition  of  the  patient  is  poor.  The  abdomen  is  always 
distended  (Fig.  92).  During  the  periods  of  diarrhoea,  we  may  have  a 


312 


TEXT-BOOK  OF  PEDIATRICS 


picture  of  pseudo-ascites,  because  the  convolutions  of  the  bowel,  filled  with 
fluid,  are  drawn  to  the  dependant  portion  of  the  abdomen  and  cause  dulness 
and  fluctuation. 

The  disease  may  continue  for  years;  periods  of  improvement  and  aggra- 
vation alternate;  growth  and  weight  are  retarded  for  months  and  even  years. 
With  puberty,  the  disease  may  recover  spontaneously,  excepting  for  a  slight 

sensitiveness.  Of  course,  growth  remains 
below  the  normal  in  a  large  number  of  cases. 
A  fatal  outcome  is  not  infrequent. 

The  diagnosis  of  chronic  dyspepsia  is 
based  principally  upon  examination  of  the 
stools.  The  reaction  and  the  test  for  starch 
with  iodine  are,  aside  from  simple  inspec- 
tion, the  chief  methods  of  macroscopic  diag- 
nosis. For  the  more  careful  determination 
of  the  results  of  digestion  of  meat,  fat,  vege- 
tables and  starch  a  microscopic  preparation 
is  essential.  The  test-meal  (A.  Schmidt) , 
appears  necessary  only  in  exceptional  cases. 
To  determine  the  integrity  of  gastric  func- 
tion, it  may  be  necessary,  particularly  in 
those  conditions  which  do  not  yield  to  ther- 
apy, to  give  a  test  breakfast. 

In  the  treatment  of  dyspepsias  of  gastric 
origin,  careful  attention  should  be  given  to 
the  avoidance  of  recurrences  and  to  the 
increase  of  the  functional  capacity  of  the 
stomach.  It  is  well  to  begin  with  stomach 
washing  accompanied  for  several  days  by 
very  scant  feeding,  without  resort,  however, 
to  actual  hunger  therapy.  Gradually  the 
diet  is  increased,  making  use  of  butter  or 
cream,  prepared  flours,  meats  and  vegeta- 
bles passed  through  a  fine  sieve.  Renewed 
anorexia  necessitates  further  reduction  of 
the  diet.  Frequent  use  of  the  stomach-tube 
and  of  lavage  at  times  becomes  necessary. 
With  continued  care  the  functional  ability 
may  be  greatly  increased  and  the  diarrhoea 
disappears.  In  severe  cases,  however,  a  year  or  more  may  pass  before  com- 
plete recovery  takes  place.  As  to  medication:  pepsin  and  hydrochloric 
acid;  tr.  rhei,  20  c.c.  (5  drams),  with  tr.  nux  vomica  2.0-5 .0  c.c.  (3^-1  dram), 
5  to  20  drops,  before  each  meal  may  be  useful. 

The  usual  treatment  of  the  ordinary  forms  of  chronic  dyspepsia  is 
dietetic.  The  basis  of  the  diet  is  flour  soup.  It  is  customary  to  give  cocoa, 
oatmeal  water,  proprietary  foods,  cereals,  boiled  rice,  with  the  addition  of 
meat  juices  and  protein  powders;  and,  later  on,  to  add  a  pap  of  measured 


Fia.  92.— Intestinal  infantilism.  Girl 
of  three  years,  76  cm.  (30  inches)  tall, 
weight  eight  kilos  (17.6  pounds),  large 
abdomen,  old  face.  (Children's  Hospital, 
Zurich,  Prof.  Feer.) 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  313 

vegetables  and  finally  meat  soups.  For  younger  children,  Liebig's  malt 
soup  is  to  be  recommended.  In  quite  a  number  of  cases,  the  intestine 
actually  recovers  so  far  that  a  transition  to  mixed  diet  is  possible.  It  is 
clear,  however,  that  this  course  is  not  proper  in  dyspepsia  due  to  carbo- 
hydrate fermentation;  but  that,  on  the  contrary,  carbohydrates  must  be 
reduced.  It  is  better  than  to  give  chiefly  meats,  white  cheese,  eggs,  vege- 
table soup,  well-mashed  vegetables,  spinach,  lettuce  and  fruit.  Carbohy- 
drates are  best  given  in  the  form  of  toast,  white  bread,  and  soups,  with  very 
fine  flour  in  quantities  adjusted  to  the  reduced  tolerance.  Taka-diastase 
in  tablet  form  is  frequently  useful.  The  diet  should  be  increased  according 
to  the  indications  given  by  examination  of  the  feces. 

Such  a  method  of  treatment  is  advantageous  in  typical  cases,  and  is  to 
be  advocated  whenever  the  carbohydrate  treatment  is  not  satisfactory. 
When  the  stools  are  acid  or  contain  starch,  this  is  especially  advisable.  The 
results  are  usually  certain.  Milk  is  hardly  ever  satisfactory  and  it  is  better 
to  discontinue  it  entirely  or  to  reduce  it  to  as  small  a  quantity  as  possible. 
Care  should  be  taken  in  the  allowance  of  sugar  or  sugared  foods;  stewed 
fruits  should  be  prepared  without  sugar.  Potatoes  are  frequently  injurious. 
At  first,  meat  should  be  given  in  chopped  form  and  vegetables  should  be 
passed  through  a  fine  sieve.  Course  vegetables  frequently  maintain  an 
irritating  fermentation  because  the  contained  starch,  surrounded  by  cellu- 
lose, escapes  digestion  in  the  upper  part  of  the  intestine.  In  children  in  the 
second  year,  protein-milk  may  be  useful. 

Similar  rules  apply  to  the  treatment  of  severe  digestive  insufficiency. 
Varied  diets  are  generally  of  great  value  in  these  cases  because  the  status  of 
these  children  is,  to  a  large  extent,  dependent  upon  psychic  factors,  and  a 
monotony  of  diet  increases  the  suffering.  The  variety  of  foods  which  these 
children  will  bear  is  surprising  and  nothing  is  more  harmful  to  them  than  an 
unbalanced  flour  and  milk  diet.  Further  indications  may  be  gained  by 
examination  of  the  stools  and  the  stomach  contents.  Frequently  it  is 
necessary  to  reduce  the  fats;  in  cases  of  achylia,  the  meat;  and  often  again 
the  eggs.  With  evident  fermentation,  at  the  beginning  of  an  acute  aggrava- 
tion, the  best  results  are  obtained  by  a  temporary  reduction  of  the  carbohy- 
drates and  even  of  the  other  food-stuffs.  Days  of  hunger,  or  longer  periods 
of  underfeeding  are  hazardous.  Little  assistance  can  be  expected  from  the 
digestive  ferments. 

It  is  hardly  necessary  to  add  that  in  regulating  the  diet  of  the  patient, 
not  only  the  quality,  but  also  the  quantity  of  the  food  and  of  its  individual 
food  components  must  be  given  careful  consideration.  Failure  of  treatment 
is  frequently  due  to  too  much  or  too  little  food.  .  A  great  influence  for 
recovery  is  also  employed  by  psychic  stimulation  and  change  of  climate. 

In  the  treatment  of  mucous  colitis,  it  is  necessary  to  increase  the  carbo- 
hydrate element  in  the  diet,  reducing  meat,  eggs,  cheese  and  the  like,  and 
giving  fruit,  coarse  vegetables  and  other  foods  containing  large  amounts  of 
indigestible  residue.  Gentle  intestinal  lavage  and  occasional  treatment 
with  oil  are  useful. 


314  TEXT-BOOK  OF  PEDIATRICS 

The  recovery  from  all  forms  of  chronic  dyspepsia  is  hastened  by  the 
improvement  of  the  general  health  and  especially  by  proper  climatic  condi- 
tions. In  the  severer  types,  one  occasionally  sees  great  improvement  at  the 
seashore  or  in  the  country.  A  water  cure  (Karlsbad)  may  at  times  be  useful. 
So  far  as  medication  is  to  be  considered  at  all,  the  methods  recommended 
in  infective  intestinal  catarrh  may  be  employed. 

ACUTE  INFECTIOUS  DISEASES  OF  THE  GASTRO-INTESTINAL 

TRACT 

Aside  from  the  actual  disturbances  of  nutrition,  we  find  many  diseases 
in  childhood  and  especially  in  infancy  which  must  be  looked  upon  as  infec- 
tions of  the  digestive  tract  caused  by  the  invasion  of  pathogenic  organisms. 
The  infection  is  often  carried  by  the  food;  the  disease-producing  organism 
may  come  from  diseased  cattle  (streptococci  from  abscess  in  the  udder,  or 
colon  bacilli  from  diarrhrea),  or  the  pathogenic  organisms  of  human  disease 
may  have  been  introduced  in  some  manner  during  its  journey  to  the  con- 
sumer. Numerous  cases  are  seen  in  which  the  infection  is  carried  directly 
from  other  individuals.  Observations  of  house  epidemics  and  especially 
ol  the  epidemic-like  outbreak  of  gastro-enteritis  in  children 's  hospitals  and 
in  institutions  for  the  care  of  infants  give  definite  proof  of  this. 

The  most  common  etiologic  factor  of  infectious  intestinal  catarrh  is 
doubtless  grippe.  Gastro-intestinal  forms  of  this  malady  in  varying  degrees 
of  severity  are  at  times  epidemic  in  extent.  In  other  cases,  blame  must  be 
placed  upon  varieties  of  the  colon  group,  upon  streptococci,  paratyphoid  or 
dysentery  bacilli,  and  occasionally  upon  the  pneumococcus,  the  B.  pyocya- 
neus,  the  B.  proteus,  etc. 

The  symptomatology  of  the  diseases  produced  by  these  different  organ- 
isms is  usually  so  variable  and  so  little  characteristic  of  any  causative 
group  that  it  is  hardly  possible  to  classify  cases  etiologicaUy.  It  seems  more 
to  the  point  to  differentiate  them  clinically. 

Catarrhal  gastro-enteritis  is  to  be  distinguished  by  its  mucopurulent  and 
occasionally,  slightly  bloody  diarrhoea,  without  indications  of  colitis.  The 
attack  occurs  suddenly  and  is  accompanied  by  a  rise  of  temperature. 
According  to  the  height  of  the  fever,  the  severity  of  the  diarrhoea  and  the 
effect  upon  the  general  health,  we  may  distinguish  mild  from  severe  cases. 
The  mild  forms  may  resemble  an  obstinate  dyspepsia  and  the  severer  may 
present  a  serious  disease-picture  with  the  appearance  of  cholera-like  symp- 
toms. With  proper  treatment,  the  disease  usually  does  not  last  longer 
than  one  to  three  weeks. 

Most  of  the  cases  may  be  traced  to  a  grippal  infection  as  shown  by  the 
coincidence  of  symptoms  of  respiratory  disorder  (coryza,  pharyngitis, 
bronchitis,  etc.).  On  this  account  they  are  frequently  termed  broncho- 
entero-catarrh.  In  young  infants,  more  especially  in  the  new-born,  and  but 
rarely  in  older  children,  one  sees  similar  disease  of  septic  origin  in  which  the 
upper  portion  of  the  intestine  presents  a  hemorrhagic,  purulent,  even  ulcer- 
ative  inflammation  of  the  mucous  membrane,  caused  by  streptococci  or 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  315 

similar  organisms.     Such  forms  usually  run  a  very  severe  course  and  fre- 
quently have  a  fatal  termination. 

In  epidemics  of  Asiatic  cholera,  children,  especially  within  the  first  ten 
years  of  life,  are  attacked  in  great  numbers  and  the  mortality  up  to  the 
fifth  year  is  very  high.  Of  infants  sick  with  cholera  about  eighty  per  cent, 
die;  during  the  second  five  years,  only  about  fifty  per  cent,  are  lost.  The 
clinical  picture  differs  little  from  that  in  the  adult.  Both  in  mild  and  more 
fully  developed  forms,  the  disease  appears  with  the  algid  stage;  and  as 
in  typhoid.  The  resemblance  to  ordinary  diarrhoea  with  vomiting,  and 
to  alimentary  intoxication,  may  be  great,  so  that  the  diagnosis,  excepting 
in  epidemics  is  very  difficult. 

Typhoid-like  gaslro-enteritis,  so-called  gastric  fever,  is  especially  dis- 
tinguished by  high  fever,  while  the  bowel  movements  may  be  only  slightly 
diarrhceal.  Other  symptoms,  excepting  a  coated  tongue  and  anorexia,  may 
be  absent,  or  the  spleen  may  be  enlarged,  while  the  patient  may  be  ex- 
tremely languid  and  may  suffer  headaches  and  vomiting.  At  tunes  icterus 
may  occur.  After  a  period  of  from  eight  days  to  three  weeks,  during  which 
a  remittent  fever  usually  persists,  recovery  sets  in  by  lysis.  The  resem- 
blance to  real  typhoid  is  often  great  and  only  the  continued  absence  of  the 
Widal  reaction  and  the  negative  bacterial  findings,  make  differential  diag- 
nosis possible. 

Dysentery-like  enteritis  (Enterocolili s) . — The  most  important  causative 
factors  of  infectious  intestinal  disease,  with  a  predominance  of  oolitic  symp- 
toms, are  the  streptococcus,  derived  probably  from  the  inflamed  udder  of 
the  cow  (the  streptococcus  enteritis  of  Escherich)  and  a  species  of  the 
colon  group  (coli  colitis) .  There  are  occasional  cases  in  which  other  organ- 
isms are  found.  This  dysentery-like  disease  is  rather  common  during  the 
first  year  and  has  been  called  follicular  enteritis.  Its  onset  is  acute,  with 
moderate  or  high  fever,  general  symptoms  of  a  serious  nature  and  se- 
vere mucous,  bloody  or  purulent  diarrhoea.  The  mucous  quality  of  the  evac- 
uations and  the  tenesmus  accompanying  them,  show  that  the  seat  of 
the  trouble  is  in  the  large  bowel.  In  favorable  cases,  the  fever  disappears  in 
from  one  to  five  days  and  recovery  begins.  Other  and  numerous  cases  are 
seen  which  take  a  different  course.  At  times,  cholera-like  conditions  arise, 
or  an  attempt  at  recovery  is  incomplete  and  the  mucous  diarrhoea  continues. 
Sometimes  we  see  intermittent  periods  of  aggravation  with  recurrence  of  all 
symptoms.  Again,  with  the  long  continuance  of  muco-sanguineous  evac- 
uations, a  severe  cachexia  may  gradually  develop,  which  may  end  fatally 
with  the  picture  of  extreme  atrophy.  In  still  other  cases  the  local  disease 
spreads  with  unusual  rapidity  and  produces  severe,  necrotic  inflammatory 
lesions  which  in  some  cases  run  their  course  with  a  high  remitting  fever. 

The  anatomic  findings  of  the  disease  are  those  of  a  sero-hemorrhagic  or 
seropurulent  hemorrhagic  inflammation  of  the  lymph  follicles  of  the  large 
intestine.  The  follicles  may  become  eroded  and  thus  lead  to  the  formation 
of  small  ulcers.  In  serious  forms  real  dysenteric  changes  in  the  mucous 
membrane,  of  greater  or  less  area,  are  seen. 


316  TEXT-BOOK  OF  PEDIATRICS 

DYSENTERY 

Dysentery  has  recently  appeared  in  epidemic  form  in  various  countries 
and,  as  such,  has  taken  its  toll  among  the  children  of  all  ages.  It  is  inter- 
esting to  note  that  the  epidemic  incidence  of  the  disease  according  to  statis- 
tics follows  very  closely  the  incidence  of  summer  diarrhoea  of  other  types. 
Its  morbidity  rises  gradually  in  July  and  drops  to  an  isolated  case  in  the  late 
autumn.  For  this  reason,  every  increase  of  intestinal  disorder  during  this 
period  should  arouse  our  suspicion. 

Etiologically,  it  is  customary  to  distinguish  two  types  or  forms  (1) 
true  dysentery,  caused  by  the  Shiga's  bacillus  and  (2)  pseudodysentery, 
caused  by  the  Flexner  and  Y-bacilli.  This  etiologic  differentiation  does  not 
signify  that  the  pseudodysentery  is  less  serious  or  of  shorter  duration.  In 
spite  of  the  lower  toxicity  developed  by  the  Flexner  and  Y-types  in  animals, 
there  is  no  great  difference  in  the  clinical  picture  of  the  two  varieties. 
Possibly  the  primary  toxic  forms  of  the  disease  is  more  grave  and  the  num- 
ber of  the  relapses  greater  with  the  Shiga  type  of  infection.  The  demon- 
stration of  the  causative  organism  is  possible  in  fresh  specimens  only  and 
even  then  not  in  all  of  the  cases.  If  the  bacteriologic  demonstration  of  the 
organism  is  impossible,  the  agglutination  test  with  the  appropriate  organism 
will  be  of  great  use.  As  a  rule,  the  agglutination  with  dilutions  as  high  as 
1 : 400  is  obtained  even  after  recovery  and  will  give  the  differential  diag- 
nosis. In  infants  the  agglutination  may  be  delayed  or  fail  entirely.  The 
incubation  period  is  short,  usually  from  five  to  seven  days.  The  onset,  gen- 
erally without  prodromes  or  with  a  day  or  so  of  non-characteristic  diarrhoea, 
is  sudden. 

It  is  convenient  to  distinguish  two  forms  according  to  the  course  the 
disease  takes.  (1)  A  form  in  which  the  infectious  symptoms  of  diarrhoea 
and  fever  predominate,  and  (2)  the  form  in  which  the  toxic  symptoms  are 
paramount.  The  extreme  dehydration  and  tendency  to  collapse  simulate 
cholera.  This  type  is  less  frequent  but  much  more  serious  than  the  first. 
Among  the  infectious  type  of  cases,  a  large  mimber  of  mild  attacks  are  seen. 
In  these  the  fever  may  last  for  only  a  few  days,  the  consciousness  is  not 
affected  and  the  diarrhoea  and  symptoms  of  intestinal  irritation  are  slight. 
In  more  severe  cases  the  fever  persists,  diarrhoea,  tenesmus  and  pain  is 
very  distressing  and  continues  for  a  long  time.  The  severe  cases  are 
characterized  by  extreme  intestinal  manifestations.  There  is  vomiting, 
anorexia  and  prostration.  These  cases  are  the  transitional  stages  to  the 
cholera-like  forms,  in  which  the  vomiting  and  terrific  purgation  form  the 
clinical  picture.  In  these  the  temperature,  mildly  febrile  for  a  short  time, 
becomes  subnormal  in  collapse  and  the  patient  presents  all  the  signs  of  a 
general  intoxication.  The  tendency  to  collapse  and  subnormal  temperature 
distinguishes  this  form  from  those  cases  of  the  first  group  in  which  there  is 
high  fever,  restlessness,  delirium  and  even  convulsions  but  which  soon 
become  convalescent. 

Very  mild  cases  are  also  encountered.  In  these  the  temperature  is  never 
very  high  and  the  bloody  mucous  stools  persist  for  only  a  day  or  two. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM 


317 


Some  of  these,  however,  go  on  to  a  chronic  stage  in  which  the  stools  always 
contain  some  mucus  and  from  time  to  time  contain  a  little  blood.  On 
the  basis  of  this  persisting  disturbance,  acute  relapses  may  occur  at 
any  time. 

These  chronic  recurring  cases  are  es- 
pecially common  in  weak  infants.  Dysen- 
tery in  infants  has  several  other 
characteristics;  the  cases  with  acute 
cholera-like  course  are  common,  and  a 
large  part  of  them  have  gastric  symptoms. 
On  the  other  hand,  the  very  mild  cases, 
usually  rather  persistent  and  with  colitis, 
may  resemble  the  more  common  chronic 
dyspepsia  so  closely  as  to  be  completely 
overlooked  and  thus  form  a  source  of 
danger  to  other  infants. 

In  the  course  of  dysentery  in  children, 
slight  rises  of  temperature  (100°  to  101°) 
may  continue  for  several  daj^s.  Goeppert 
finds  recurrences  in  about  fifteen  per  cent, 
of  the  cases.  In  true  dysentery,  these  are 
said  to  be  especially  severe.  Undoubtedly 
this  second  attack — as  in  scarlet  fever — is 
a  result  of  the  action  of  the  dysentery 
toxin.  Complications  and  sequelae,  such 
as  conjunctivitis  and  arthritis,  are  much 
less  common  than  in  adults.  Edema, 
however,  is  very  common  especially  in 
undernourished  infants.  After  the  dysen- 
tery is  completely  cured,  there  may  still 
remain  a  certain  sensitiveness  of  the  diges- 
tive tract  which  will  require  careful 
regulation  of  the  diet  for  months. 

Pathologic  changes  do  not  differ  from 
those  in  the  adult.  The  prognosis  varies 
according  to  the  epidemic  and  age  of  the 
patient.  The  mortality  among  children 
of  one  to  two  years  is  twenty-five  to  thirty 
per  cent.  In  older  children  it  is  lower. 

A   special   danger   of   the   infectious 
gastro-intestinal    diseases    lies   in    their 
tendency  to  complications.   The  most  im- 
portant of  these  are  nephritis  and  pneu- 
monia, pyemia,  cystopyelitis,  the  more  variable  pyodermias,  and  a  general 
septicemia  arising  from  the  mucosa  of  the  diseased  intestine.    More  impor- 
tant than  all  of  these  is  the  association  of  a  secondary  disturbance  of  nutri- 
tion with  the  infective  disease.    It  may  be  readily  understood  that  the 


318 


TEXT-BOOK  OF  PEDIATRICS 


normal  metabolic  functions  of  the  intestine  do  not  take  place  in  the  seriously 
diseased  organ  and  that  acid  fermentation,  which  causes  dyspepsia,  occurs 
easily.  This  secondary  dyspepsia  may  go  on  to  alimentary  decomposition 
and  alimentary  intoxication,  which  will  overshadow  the  original  disease,  and 
may  carry  the  patient  to  the  point  of  hazard.  Inanition,  due  to  the  custom- 
ary carbohydrate  feeding,  may  add  its  menace.  It  may  hardly  be  doubted 
that  not  only  numerous  cholera-like  aggravations,  but  also  a  larger  per- 
centage of  resultant  atrophic  conditions,  are  not  due  to  infection,  but  to 
starvation  and  to  other  forms  of  secondary  disturbance  of  nutrition.  Very 
probably,  a  certain  number  of  the  severe  ulcerative  type,  with  its  various 
complications,  are  due  to  the  same  cause.  Underfeeding  alone  will  weaken 
the  total  resistance  of  the  body,  reduce  the  general  defense  against  bacteria 
and  permit  a  local  infection  to  spread  unimpeded. 

The  diagnosis  of  intestinal  infections  in  general  offers  no  great  difficulty. 
It  is  important,  first  of  all,  to  differentiate  them  from  alimentary  intoxi- 
cation and  to  establish  definitely  the  importance,  of  the  part  played  by  a 


FIG.  94. — Chart  of  a  case  of  severe  dysentery  in  a  child  of  four.    Fatal  termination. 
Subnormal  temperature. 

complicating  dyspepsia  or  a  toxic  disturbance  of  nutrition.  The  results  of  a 
discontinuance  of  the  food  supply  give  a  great  deal  of  information.  Expe- 
rience shows  that  in  the  infant  a  diagnosis  of  the  milder  dyspepsia-like 
forms  causes  some  difficulty.  The  obstinacy  of  the  diarrhrea,  in  spite  of  the 
usual  treatment  for  dyspepsia,  should,  arouse  suspicion.  If  fever  does  not 
disappear  when  the  food  is  withdrawn,  a  final  decision  must  be  made  in  favor 
of  infection. 

The  etiologic  factors  can  be  determined  only  by  careful  bacteriologic 
examination  of  the  feces  and  of  the  blood  together  with  agglutination  tests. 
The  prognosis  of  the  various  forms  of  gastro-enteritis  in  older  children  is 
generally  favorable.  In  dysentery  and  cholera,  it  is  of  course,  characteristic 
of  those  diseases.  In  younger  children,  the  prognosis  is  dependent  upon  the 
ability  of  the  physician  to  apply  proper  dietetic  measures.  If  he  is  successful 
in  avoiding  a  serious  secondary  disturbance  of  nutrition,  which  is  possible 
to-day  in  a  great  number  of  cases,  he  will  have  a  surprisingly  large  percent- 
age of  recoveries;  if  he  fails,  his  statistics  will  be  far  from  gratifying. 

Treatment  should  begin  by  emptying  the  intestine  [calomel  0.05-0.1  gm. 
(grs.  1-2),  in  three  or  four  doses].  In  the  dysenteric  forms,  one-fourth  to 
one-half  of  a  teaspoonful  of  castor  oil,  every  two  hours,  for  twenty-four  to 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  319 

thirty-six  hours,  is  recommended.  The  subsequent  treatment  is  chiefly 
a  question  of  diet.  The  general  concensus  of  opinion  among  authorities  is 
favorable  to  flour  feeding?  with  the  addition  of  Liebig  's  malt  soup  as  signs 
of  improvement  appear,  a'nd  with  a  gradual  and  careful  return  to  a  mixed 
diet.  The  procedure  should  be  practically  the  same  as  that  advised  for 
dyspepsia.  Usually  the  condition  of  the  stools  is  made  to  govern  the  quali- 
tative and  quantitative  increase  of  food.  If  this  is  followed  out  too  carefully, 
the  patient  is  usually  underfed  for  rather  long  periods  and,  as  has  already 
been  said,  this  is  extremely  hazardous.  More  recent  experiences  show  that 
the  increase  of  the  food  need  not  be  very  gradual.  In  fact,  much  better 
results  are  obtained,  especially  in  children  in  the  second  and  third  years  in 
whom  the  infectious  symptoms  predominate,  if  liberal  amounts  of  food  are 
given.  The  only  precaution  necessary  is  to  see  that  the  food  is  easily 
digested,  and  that  it  will  not  leave  undigestible  portions  that  may  irritate 
the  colon.  Milk,  sugar,  flour,  prepared  cereals,  finely  chopped  meat,  egg, 
broth  and  fruit  juices  may  be  given  in  quantities  large  enough  to  prevent 
loss  of  weight.  Coarse  food  should  not  be  given  until  the  stool  has  been 
normal  for  several  weeks.  In  infants,  too,  the  food  requirement  must  be 
fulfilled  as  soon  as  possible.  These  younger  children  should  be  treated  as 
prescribed  for  chronic  dyspepsia  and  decomposition.  Piotein-milk  or  its 
various  substitutes  are  of  great  value. 

In  the  cases  with  the  severe  cholera-like  course,  on  the  contrary,  the 
replacement  of  the  water  lost  by  the  severe  dehydration  must  be  the  first 
consideration.  For  this  purpose  some  authors  advise  the  use  of  diluted 
whey  (1 : 1  oatmeal  gruel)  in  gradually  increasing  amounts  according  to  age. 
Better  still  is  buttermilk,  at  first  without  carbohydrate  additions.  Subcu- 
taneous or  intraperitoneal  injection  of  physiologic  salt  solution  or  procto- 
clysis  may  be  necessary.  The  persistent  vomiting  is  to  be  combated  by  the 
use  of  gastric  lavage,  or  medicinally,  by  atropin,  novocaine,  etc.  As  soon  as 
the  case  has  improved  sufficiently  to  permit  the  ingestion  of  food,  the  regime 
described  for  intoxication  should  be  instituted  in  young  infants.  In  older 
children,  the  food  should  be  given  in  liberal  amounts  as  soon  as  possible 

In  the  way  of  medication,  good  results  are  obtained  early  in  the  disease 
with  opium  [0.001-0.02  gm.(M'o-//3gr.)  according  to  age,  3-5  times  daily] ;  later 
tannigen  or  tannalbin  [up  to  2.0  gms.  (30  grs.)  per  day];  quinine  tannate 
[0.1-0.3  gm.  (2-5  grs.)  three  times  daily];  lead  acetate,  [0.003-0.005  gm. 
(//2Q-}'l2  grO  three  times  daily];  etc.,  may  be  used.  In  the  later  stages, 
those  who  still  believe  in  irrigation  may  use  lavage  of  the  large  intestine  w^th 
a  solution  of  aluminum  acetate  (1-500),  albargin  (1-1000),  physiologic  salt 
solution,  or  bismuth  salicylate  (1-8  per  cent.)  in  gruel.  To  this  should  be 
added  counterirritant  measures  and  hydrotherapy  to  quiet  abdominal  pains 
and  restlessness  and  to  reduce  high  temperature. 

The  excreta  ehould  be  disinfected  in  the  customary  way.  It  is  well  to 
use  materials  for  diapers  and  bed-pads  that  can  be  burned  immediately. 
Nurses  and  others  in  contact  with  the  patient  should  be  instructed  as  to  the 
danger  to  which  they  themselves  and  the  community  are  exposed  in  the 


320 


TEXT-BOOK  OF  PEDIATRICS 


spread  of  infection;  since  adults  may  contract  either  dysentery  or  dysentery- 
like  diarrhoea.  In  groups  of  cases,  the  source  of  the  infection  (food,  water, 
germ-carriers)  must  be  investigated. 


Secondary  tuberculous  disease  of  the  intestine  is  usually  brought  on  by 
swallowing  tubercle  bacilli  which  have  come  from  the  lung.  It  is  as  fre- 
quent in  children  of  every  age  as  it  is  in  later  life.  Primary  intestinal  tuber- 
culosis in  which  the  intestine  is  the  original  and  the  only  seat  of  the  disease 
is  much  less  common.  Great  difference  of  opinion  obtains  among  pathol- 
ogists  as  to  the  frequency  of  the  primary  forms;  nevertheless,  the  occur- 
rence of  primary  pulmonary  tuberculosis  more  than  doubles  the  highest 
estimate  of  the  intestinal  form.  The  younger  the  child,  the  less  frequent  is 
the  primary  intestinal  infection;  in  infancy  only  a  few  cases  are  recorded. 

The  food  is,  in  many  cases,  the  source  of  a  primary  infection  of  the  bowel 
in  others,  it  is  a  question  of  dirt  infection.  Whether  animal  tuberculosis 


FIQ.  95. — Rigidity  of  the  abdominal  muscles  seen  in  tuberculous  stenosis. 
Child  of  two  years. 

from  the  use  of  the  meat,  and  especially  from  the  use  of  the  milk  of  tuber- 
culous cattle,  may  infect  the  child  is  a  question  of  special  interest.  In  all 
probability,  it  is  a  minor  matter  as  compared  with  the  transmission  of 
human  tuberculosis. 

Pathologic  examination  shows  that  intestinal  tuberculosis  begins  with 
small  tubercles,  which  break  down  and  form  ulcers  with  undermined  edges. 
By  the  confluence  of  these,  larger  loss  of  substance  occurs,  aro.und  which 
new  tubercles  arise.  The  intestine  is  frequently  covered  with  circular 
ulcers.  In  the  immediate  neighborhood,  peritoneal  adhesions  are  formed 
and  infection  extends  to  the  mesenteric  lymph  nodes,  (q.  v.}.  Frequently 
these  ulcers  cicatrize  and  thus  give  rise  to  stenosis.  Kinks  of  the  intestine 
may  be  caused  by  peritoneal  adhesions.  The  most  important  changes  are 
seen  in  the  small  intestine  and  in  the  caecum,  while  the  colon  is  little,  if  at 
all  affected. 

Symptoms. — Early  in  the  illness  the  child  is  fretful,  tires  readily,  has 
irregular  fever,  and  soon  develops  diarrhoea  and  abdominal  pains.  The 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  321 

intestine  is  sensitive  at  points  to  pressure;  the  abdomen  is  usually  little,  if  at 
all,  distended.  In  the  stools  one1  may  find  mucus  and,  by  microscopic 
examination,  blood.  The  disease  is  of  long  duration,  is  marked,  in  severe 
cases,  by  extreme  cachexia  and  hectic  fever;  and  usually  terminates  fatally. 
Remissions  may,  however,  occur  and  even  a  complete  recovery  is  possible. 
Scar  tissue,  intestinal  stenosis  due  to  the  contraction  of  scar  tissue,  com- 
pression of  the  lumen  of  the  bowel  caused  by  adhesions  or  kinks,  may  remain 
and  demand  special  treatment  (Fig.  95).  Complications  by  way  of  the  per- 
foration of  ulcers  with  accompanying  acute  peritonitis,  bleeding  from  eroded 
intestinal  vessels,  tuberculous  peritonitis,  general  miliary  tuberculosis  and 
tuberculous  meningitis  may  be  noted. 

The  diagnosis  is  not  always  easy.  It  turns  upon  the  long  continued 
fever,  the  obstinate  diarrhoea,  the  synchronous  presence  of  other  symptoms 
of  tuberculosis,  and  the  demonstration  of  the  bacillus  by  sedimentation 
methods.  A  positive  von  Pirquet  reaction  does  not  prove  definitely  that 
the  symptoms  are  due  to  intestinal  tuberculosis,  for  it  may  be  produced  by 
other  latent  foci. 

In  the  treatment,  one  must  strive  to  counteract  tne  extreme  cachexia, 
and  to  prevent,  by  suitable  diet,  the  occurrence  of  secondary  fermentation 
dyspepsia.  For  the  rest,  general  measures  (climatic  treatment,  etc.), 
which  give  any  promise  of  reeults,  may  be  adopted.  Of  medicinal  remedies, 
the  heavy  metals  are  recommended.  Bismuth  salicylate  or  subgallate 
[0.5-1.0  gm.  (7-15  grs.),  several  times  daily],  lead  acetate,  [0.003-0.005  gm. 
(M'(rM'o  gr.)  for  several  days],  ferric  pyrophosphate,  (1^  per  cent,  solu- 
tion, a  teaspoonful,  twice  a  day),  may  be  tried.  Opium  and  the  vegetable 
astringents  may  be  used. 

INTESTINAL  POLYPOSIS 

Symptoms. — In  children,  the  passage  of  several  drops  or  even  of  larger 
quantities  of  fresh  blood  from  the  anus,  usually  with  the  bowel  movement, 
but  more  rarely  alone,  has  been  frequently  observed.  Barring  the  readily 
recognized  bleeding,  caused  in  the  presence  of  fissures  by  the  passage  of  a 
hard  stool,  and  the  very  rare  bleeding  from  hemorrhoids  and  malignant 
tumors,  such  blood  comes  from  small  benign  tumors  of  the  rectum.  .They 
are  papillomatous  in  structure  and  occur  in  three  varieties.  The  so-called 
rectal  polypus,  which  has  a  pedicle  and  grows  to  about  the  size  of  a  cherry, 
is  one  form.  This  may  appear  at  times  in  the  anus.  The  oozing  of  blood 
from  one  or  more  points  of  an  apparently  unchanged  mucous  membrane, 
which,  upon  closer  examination,  shows  small  wart-like  hyperplasise,  con- 
stitutes another  type.  In  the  third  and  more  severe  class  of  cases,  a  real 
intestinal  polyposis  exists;  the  entire  lower  portion  of  the  intestine,  or  even 
the  entire  bowel  being  covered  with  innumerable  and  relatively  large  wart- 
like  polypoid  tumors. 

For  absolute  diagnosis,  digital  examination  is  only  occasionally  satis- 
factory, because  the  tumors  are  small  and  very  soft  and,  therefore  cannot  be 
recognized  by  touch.  One  should  make  use  of  a  rectoscope  of  small  calibre. 

Single  tumors  are  harmless.  The  true  polyposis,  on  the  other  hand,  may 
21 


322  TEXT-BOOK  OF  PEDIATRICS 

cause  a  dangerous  anemia  because  of  the  constant  loss  of  blood.  This  may 
even  occur  when  the  loss  of  blood  is  very  small.  Major  cases  often  take  a 
course  similar  to  that  of  chronic  colitis,  in  the  later  stages  of  which  severe 
cachexia  and  edema  may  appear  in  addition  to  the  anemia.  In  these  cases, 
the  prognosis  is  very  unfavorable. 

The  treatment  consists  in  the  removal  of  the  polypi  with  the  scissors 
or  snare  under  a  local  anesthetic.  Bleeding  from  the  smaller  tubercles  may 
be  controlled  by  the  use  of  caustics  or  corrosives,  trichloracetic  acid,  or 
hydrogen  peroxide.  In  intestinal  polyposis  the  repeated  use  of  both 
methods  may  be  successful.  When  a  large  portion  of  the  colon  is  affected 
and  to  a  high  point,  very  little  can  be  expected  from  treatment. 

NERVOUS  GASTRO-INTESTINAL  DISEASES 

CONGENITAL  SPASTIC  PYLORIC  STENOSIS 

Hypertrophic  Stenosis  of  the  Pylorus. — The  most  noticeable  symptom 
of  this  condition  is  violent,  persistent  vomiting,  accompanied  in  severe 
cases  by  pain,  spasmic  deglutition  and  choking.  While  symptoms  usually 
begin  during  the  second  or  third  week  of  life,  they  may  develop  earlier  or 
later  and  may  not  occur  before  the  third  or  fourth  month.  The  vomitus 
does  not  contain  bile  and  is  usually  extremely  sour,  giving  a  strong  re- 
action for  free  hydrochloric  acid.  The  patients  usually  show  either  no 
gain  in  weight,  or  a  gradually  progressive  emaciation.  They  pass  small 
amounts  of  urine  and  are  obstinately  constipated.  The  abdomen  is  re- 
tracted, but  prominent  at  the  epigastrium.  Epigastric  rigidity  is  observed 
and  marked  peristaltic  waves,  passing  from  left  to  right  (Fig.  96),  suggest 
the  conclusion  that  the  emptying  of  the  organ  is  obstructed.  As  a  matter 
of  confirmation  one  may  find,  upon  careful  palpation,  a  small,  movable, 
cylindrical  mass  at  the  right  border  of  the  rectus  under  the  liver. 

Pathologic  Anatomy. — At  autopsy,  the  tumor  above  described  is  found 
to  be  the  thickened  pylorus,  surrounded  by  a  hypertrophied  musculature 
and  the  hypertrophied  pars  pylorica,  firmly  contracted  to  form  a  hard, 
almost  cartilaginous,  tumor-like  mass,  several  centimetres  long  (Fig.  97). 
This  contracture  causes  a  stenosis  of  the  stomach  exit,  which  accounts  for 
the  clinical  findings.  Much  greater  pressure  is  necessary  to  force  this 
contracture  than  is  required  in  the  normal  systolic  stomach  at  autopsy. 
Rare  cases  of  "simple  pylorospasm"  are  also  seen.  These  present  all  the 
clinical  symptoms  of  a  hypertrophy,  but  show  no  pathology  at  autopsy. 

A  positive  explanation  of  the  anatomic  findings  has  not  been  given. 
Most  observers  are  of  the  opinion  that  it  is  a  condition  of  primary  pyloro- 
spasm with  a  secondary  compensatory  muscular  hypertrophy.  The  actual 
cause  of  the  disease  is  still  under  very  active  discussion.  It  is  doubtless  a 
neurosis  which,  according  to  the  history,  is  dependent  upon  a  hereditary 
nervous  tendency  which  produces  first  pylorospasms  and  latterly  hyper- 
aesthesia,  hyperkinesis,  and  probably,  also,  hypersecretion. 

The  disease  is  found  especially  in  breast-fed  infants  and  even  in  those 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  323 

who  have  not  suffered  from  any  errors  in  the  feeding  technic.  It  has  often 
been  observed  in  successive  children  of  the  same  family.  In  a  certain  per- 
centage of  cases,  one  sees  ptotic  conditions,  not  only  of  the  stomach  but  of  the 
remaining  abdominal  organs,  and  a  general  muscular  atony  is  demonstrable. 

The  diagnosis  is  readily  made  because  of  the  early  appearance  of  the 
disorder  and  its  typical  symptoms.  The  simple  nonhypertrophic  pyloro- 
spasm  is  much  more  liable  to  lead  to  confusion.  In  rare  cases  a  similar 
picture  is  produced  by  congenital  stenosis,  by  the  pressure  of  a  ptotic  liver 
upon  the  duodenum,  and  by  compression  from  peritoneal  adhesions,  etc. 
The  absence  of  bile  from  the  vomited  matter  contraindicates  stenosis  in  the 
lower  part  of  the  duodenum. 

The  course  and  termination  of  the  disease  are  dependent  upon  its 
severity,  which,  in  turn,  is  governed  by  the  completeness  of  the  stenosis  and 
the  persis'tence  of  vomiting.  Mild  cases  may  be  recognized  by  the  fact  that 
the  loss  of  weight  is  relatively  gradual.  The  weight  may  be  even  stationary. 


FIG.  96. — Gastric  peristalsis  in  spastic  plyoric  stenosis.     (University,  Heidelberg,  Prof.  Feer.) 

A  bowel  movement  occurs  at  least  every  second  day.  In  these  conditions, 
one  may  be  certain  of  recovery.  After  several  weeks,  at  least  after  two  or 
three  months  or  more,  the  vomiting  becomes  less  frequent  and  the  bowel 
movements  more  numerous  and,  with  the  increasing  possibility  of  adequate 
feeding,  a  rapid  increase  of  weight  takes  place  and  complete  recovery 
finally  follows.  Nor  do  these  children  show  any  particular  tendency  to 
gastric  disorders  in  later  life.  In  the  more  serious  cases,  the  loss  of  weight  is 
rapid  from  the  beginning,  the  bowel  movements  occur  at  long  intervals, 
and  the  large  daily  losses  of  weight  do  not  cease  even  when  the  remission 
of  the  spasm  permits  of  a  temporary  increase  of  the  food  supply.  Usually 
these  patients  soon  reach  a  peculiar  state  of  apathy,  eliminate  sugar  in  the 
urine,  upon  taking  even  small  quantities  of  food,  and  simply  cannot  be  fed. 
The  condition  is  nothing  more  than  one  of  extreme  inanition.  At  this 
stage,  it  is  absolutely  impossible  to  save  the  patient;  excepting,  per  chance, 
by  operation. 

In  the  treatment  of  pylorospasm,  the  parents  must  be  warned  first 
against  the  customary  attempt  to  quiet  the  stomach  by  the  withdrawal  of 


324  TEXT-BOOK  OF  PEDIATRICS 

food,  or  the  substitution  of  tea  or  gruels.  Starvation  gives  no  results,  and 
the  risk  of  injuring  the  young  and  poorly  resistant  child  by  a  period  of 
hunger,  and  of  converting  a  mild  case  into  a  serious  one,  is  very  great. 

No  method  of  feeding  is  known  which  is  certain  to  relieve  the  vomiting. 
The  best  plan  is  to  feed  breast-milk,  for  with  this  the  danger  of  a  disturb- 
ance of  nutrition  complicating  the  inanition  is,  to  say  the  least,  reduced  to 
a  minimum. 

Various  methods  of  feeding  are  advised  by  various  physicians.  Heub- 
ner  advocates  regular  three-hour  feedings,  permitting  the  child  to  ingest  as 
much  as  it  wishes  without  considering  the  vomiting.  Ibrahim  does  not 
put  the  infant  to  the  breast  at  once,  but  gives  very  small  quantities  of 
expressed  breast-milk,  cooled  in  ice,  at  frequent  feedings;  allowing  at  first, 
10  c.c.  every  hour;  then,  with  correspondingly  increasing  intermissions,  15, 


FIG.  97. — Stomach  in  spastic  pyloric  stenosis.     CSemidiagrammatic.) 


20,  25  c.c.,  and  so  on.  With  the  ingestion  of  300  c.c.  the  danger  of  death  from 
starvation  is  over.  Of  methods  of  artificial  feeding,  the  fat-free  prepa- 
rations (buttermilk,  skim-milk) ,  are  entitled  to  first  consideration,  because 
of  the  experience  with  them  in  simple  pylorospasm;  but  their  successful  use, 
if  there  be  any,  is  by  no  means  so  well  understood  in  this  form  of  disease. 
Sometimes  results  are  attained  with  concentrated  food.  There  are  no 
contraindications  to  this  A  tablespoonful  of  Karlsbad  water  before  each 
meal  is  useful.  Hot  applications  for  periods  of  two  hours,  three  times  a  day, 
may  be  directed.  Medication  is  of  very  little  use.  Tincture  of  opium, 
Mo-Ko  drop  to  the  dose,  cocaine,  novocaine,  alypin  (Ko  of  gr.  to  the  dose, 
shortly  before  feeding),  anesthesin  (3  per  cent,  in  mucilage  acacia;  one 
teaspoonful,  before  feeding)  and  similar  remedies  may  be  tried.  Stomach 
washing  is  recommended  by  some  and  opposed  by  others.  To  counteract  the 
tendency  to  the  undue  loss  of  water,  injections  of  physiologic  saline  solu- 
tion may  be  used. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  325 

Enteroclysis  may  well  be  substituted  for  hypodermoclysis  by  means  of  a 
long  tube  or  thin  Nelaton  catheter,  held  in  place  by  adhesive  plaster.  The 
following  solution  may  be  used:  sodium  chloride  7.0,  potassium  chloride  0.1, 
calcium  chloride  0.2,  water  1000  grams.  It  is  possible,  with  care,  to  give  the 
enteroclysis  twice  a  day  for  two  hours  each  time,  at  the  rate  of  30  drops 
per  minute;  in  this  way  the  patient  receives  upwards  of  400  c.c.  (18  ounces), 
of  fluid  per  day.  In  some  cases  this  seems  to  have  a  directly  favorable  in- 
fluence upon  the  vomiting.  Used  for  so  short  a  time,  the  tube  will  hardly 
cause  decubitus. 

As  the  stomach  retains  larger  quantities,  it  is  advisable  to  increase 
the  food  very  gradually  at  first.  Some  children  are  so  severely  injured 
by  the  long  inanition  that,  upon  receiving  large  amounts  of  food  too 
early,  they  become  the  victims  of  a  severe  disturbance  of  nutrition,  which 
takes  the  form  of  an  alimentary  intoxication  which  might  have  been 
avoided  by  better  care. 

Recently,  very  good  results  have  been  obtained  by  passing  a  catheter 
into  the  duodenum,  according  to  the  method  of  Alfred  Hess.  The  long 
Nelaton  tube  is  carefully  pushed  through  the  stomach  until  it  passes  the 
pylorus.  This  can  be  recognized  by  the  fact  that,  upon  moving  it  gently  to 
and  fro,  the  resistance  is  greater  than  it  is  in  the  stomach.  Food  is  slowly 
introduced  through  the  catheter,  the  procedure  being  carried  out  several 
times  daily.  Frequently  an  increase  in  weight  begins  almost  immediately 
and  usually  the  condition  so  improves  that  in  a  short  time  progress  may  be 
made  without  the  tube. 

If  duodenal  catheterization  is  not  successful  and  the  child  loses  weight 
rapidly,  surgical  interference  must  bo  considered.  The  best  and  most 
rapid  method  seems  to  be  longitudinal  incision  of  the  hypertrophic  pylorus 
leaving  the  mucous  membrane  intact  without  suturing  (Ramstedt).  It  is 
difficult  at  present  to  state  the  indications  for  operation  definitely.  This 
course  seems  advisable  when  the  tissue  loss  approaches  one-third  of  the 
previous  body-weight.  When  rapid  weight-loss  is  progressive  it  may  be 
better  to  operate  earlier,  because  with  so  severe  an  inanition  a  serious 
weakening  of  the  organism  is  quickly  threatened  and  a  longer  period 
of  waiting  may  make  the  possibility  of  repair  doubtful.  Children  who 
have  passed  into  the  comatose  condition  above  described  are  lost  under 
any  circumstance. 

HABITUAL  AND  UNCONTROLLABLE  VOMITING  OF   INFANTS 

SIMPLE  PYLOROSPASM 

Many  infants  habitually  vomit  large  or  small  quantities  of  food.  If 
this  is  a  means  of  getting  rid  of  an  excess,  it  can  hardly  be  called  a  disease ; 
it  must  be  considered  as  such,  however,  when  it  continues  in  spite  of  care- 
fully regulated  or  scant  quantities  of  food.  This  vomiting  may  occur  with- 
out any  preceding  gastric  disorder.  In  many  cases,  the  habit  associates 
itself  with  dyspepsia  and  continues  for  a  long  time  after  recovery  from  that 
disease.  As  a  rule,  an  accompanying  mild  ischochymia  (gastric  dilatation), 
is  demonstrable. 


326  TEXT-BOOK  OF  PEDIATRICS 

In  some  cases,  the  vomiting  becomes  so  severe  that  inanition  results 
even  to  so  serious  a  degree  as  in  hypertrophic  stenosis.  The  peristaltic 
waves,  however,  are  not  seen,  there  is  no  pyloric  tumor  and  the  constipa- 
tion is  not  so  obstinate.  On  the  contrary,  mucous  watery  stools  are  usual, 
in  spite  of  the  small  quantities  of  nourishment  that  pass  into  the  bowel. 

This  condition,  like  the  hypertrophic  form,  is  probably  dependent  upon 
an  abnormal  nervous  irritability.  Whether  this  is  merely  a  hypersesthesia 
of  the  mucous  membrane,  or  whether  pylorospasm  is  coexistent,  is  a  moot 
question.  Hypertrophy  of  the  pyloric  musculature  is  not  found  at  autopsy. 

The  prognosis  is  favorable  under  suitable  treatment;  if  errors  are  made 
the  patient  may  die  of  starvation.  Two  or  three  months  of  time  is  necessary 
to  complete  the  recovery. 

Treatment. — Those  cases  which  develop  under  artificial  feeding  are 
quite  certain  to  be  cured  with  breast -milk;  but,  as  in  the  hypertrophic 
form,  considerable  time  may  be  necessary  before  improvement  is  noticeable. 
Usually  results  are  more  rapidly  obtained  by  giving  a  fat-free  diet  (skim- 
milk  or  buttermilk),  with  the  necessary  carbohydrate  additions.  Alkali 
waters  (Karlsbad),  are  sometimes  useful.  Gastric  lavage  is  not  certainly 
helpful.  Mild  cases  may  sometimes  be  favorably  influenced  by  the  use  of 
milk  treated  with  a  coagulating  ferment,  e.  g.,  pegnin,  according  to  the 
method  of  V.  Dungern.  For  young  infants  concentrated  food,  and  with 
older  children,  a  solid  diet  is  often  beneficial.  In  addition  to  remedies  noted 
for  the  hypertrophic  form,  sodium  citrate  (2  per  cent,  solution,  one  table- 
spoonful,  before  each  feeding),  and  protargol  (0.2  per  cent,  solution,  one  tea- 
spoonful,  before  feeding),  are  also  recommended.  Often  the  vomiting  has 
disappeared  under  the  use  of  fat-free  food.  Two  or  three  months  are 
usually  necessary  before  an  ordinary  diet  can  be  employed  without  recur- 
rences of  vomiting. 

THE  PERIODIC  VOMITING  OF  OLDER  CHILDREN 

This  term  applies  to  repeated  paroxysms  of  vomiting,  rarely  lasting  over 
a  few  days  or  a  week,  accompanied,  as  a  rule,  by  fever  and  other  disturbances 
of  digestion.  Very  frequently,  indeed  almost  constantly,  acetonemia, 
acetonuria  and  an  acetone  odor  to  the  breath  are  noted.  Milder  forms 
closely  resemble  dyspepsia,  with  constipation  and  a  tendency  to  vomiting. 
It  is  questionable  whether  cases  have  been  observed  in  early  infancy.  In 
the  second  year,  however,  the  condition  has  been  known.  Between  the  ages 
of  four  and  eight  years  it  occurs  commonly;  with  puberty,  the  predisposi- 
tion ceases. 

Each  attack  begins  with  premonitory  symptoms;  such  as  change  in  dis- 
position, gastric  symptoms  or  diarrhoea;  then,  the  vomiting  begins  suddenly 
and  is  repeated  at  short  intervals.  Nothing  will  stop  it  and  the  child  is 
apparently  in  a  seriously  exhausted  state.  A  strong  acetone  odor  is  notice- 
able in  the  urine  and  in  the  expired  air:  hence,  the  French  phrase  "  Vomisse- 
ment  incoercibles  avee  acetoncemie."  Constipation  is  usual;  icterus  is 
sometimes  present;  temperature  is  usually  slightly  increased.  After  con- 
tinuing unabated  for  a  varying  period,  the  attack  passes  suddenly;  the 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  327 

patient  makes  a  rapid  recovery,  to  suffer,  after  a  week  or  a  month  or  more, 
another  attack.  The  exact  nature  of  the  condition  is  not  understood. 
It  rests,  undoubtedly,  upon  a  constitutionally  nervous  quality.  This  is 
shown  by  the  frequent  occurrence  of  cases  among  the  well-to-do,  by  the 
usual  presence  of  other  neuropathic  symptoms,  and  by  the  occasional  bene- 
ficial effects  of  suggestive  treatment.  Some  authors  class  the  disease  as  a 
form  of  hysteria,  but  this  does  not  add  much  to  its  etiology.  It  is  probably 
a  question  of  crisis  in  the  metabolic  functions,  but  the  significance  of  the 
anomalies  of  metabolism  which  have  been  observed  is  not  yet  clear.  Hecker 
believes  it  to  be  a  disturbance  of  intermediate  fat  metabqlism.  The  recent 
observation  that  attacks  are  often  brought  on  by  the  withdrawal  of  carbo- 
hydrates from  the  food,  tends  in  the  same  direction.  At  many  points  a 
relationship  to  migraine  is  indicated. 

In  the  first  attack,  great  care  should  be  taken  in  diagnosis,  for  peritonitis, 
appendicitis,  or  meningeal  disease  may  have  a  similar  onset.  A  history  of 
previous  attacks  is  of  value  in  diagnosis,  but  even  this  may  be  misleading, 
for  brain  diseases  may  cause  recurrent  attacks  due  to  variations  of  intra- 
cranial  pressure.  The  prognosis  of  the  individual  attack  is  good.  Probably 
a  few  deaths  have  been  wrongfully  ascribed  to  this  condition.  In  treatment, 
ordinary  methods,  as  hot  applications,  small  quantities  of  iced  drinks, 
narcotics  [chloroform  water,  cocaine,  or  better  still,  novocaine  or  alypin 
3-5  milligrams  (HirHo  g1"-)  etc.],  may  be  tried.  Water  should  be  supplied 
by  rectum  or  subcutaneously.  Suggestive  methods  may  avail,  a  subcuta- 
neous injection  of  sterile  water  possibly  having  such  an  effect.  During  inter- 
vals between  the  attacks  the  neuropathic  tendency  should  be  treated  by 
hygienic,  dietetic  and  pedagogic  methods. 

NERVOUS  VOMITING 

In  many  sensitive  and  constitutionally  nervous  children,  an  habitual 
vomiting,  due  to  external  influences,  may  appear  from  time  to  time;  this 
does  not  create  any  constitutional  disturbance  but  is  most  disagreeable. 
Excitement  may  be  a  cause,  as  in  the  well-known  vomiting  of  school  chil- 
dren, occurring  on  their  way  to  school  in  the  morning.  In  others,  a  peculiar 
sensitiveness  of  the  pharyngeal  reflex,  responsive  to  certain  sensations  in  the 
pharynx,  has  probably  some  relation.  Agajn,  the  cause  is  sometimes  purely 
psychic,  being  produced  by  an  abnormal  repugnance  to  certain  foods.  If 
the  vomiting  is  repeated  often  enough,  it  probably  becomes  a  reflex  habit 
which  may  appear  responsively  to  a  feeling  of  dislike  or  even,  in  extreme  ^ 
cases,  to  pleasurable  excitement.  Very  frequently  children  vomit  at  will, 
knowing  that  it  will  have  an  impressive  effect  upon  spectators. 

Common  as  this  condition  is,  great  care  must  be  taken  in  diagnosis;  all 
other  possibilities,  as  gastric  diseases  and  especially  brain  diseases,  being 
considered.  Many  a  case  of  brain  tubercle  has  gone  on  for  months  under  a 
diagnosis  of  harmless  nervous  vomiting,  until  other  symptoms  have  indi- 
cated the  actual  condition.  Disturbances  of  vision  (strabismus,  astig- 
matism), may  now  and  then  cause  the  vomiting,  which  will  disappear  after 
their  correction.  The  general  condition  of  the  child  should  be  considered 


328  TEXT-BOOK  OF  PEDIATRICS 

first.  If  it  is  not  entirely  well,  otherwise,  great  care  should  beexercised.  The 
treatment  should  be  general  and  directed  to  the  nervous  cause.  Skilful 
educational  influence,  energetic  verbal  suggestion,  coupled  with  such  occa- 
sional suggestive  treatment  as  faradization,  plaster  applications,  etc.,  may 
bring  about  recovery  in  a  short  time. 

NERVOUS  ANOREXIA 

Loss  of  appetite,  to  which  no  other  cause  revealed  in  the  pathologic 
findings  of  the  digestive  apparatus  can  be  assigned,  and  reason  for  which 
must  be  sought  in  the  neurotic  field,  is  commonly  called  nervous  anorexia. 
In  only  a  part  of  such  cases  is  a  general  neuropathic  constitution  an  ade- 
quate cause. 

These  cases  vary  widely  in  character  and  a  careful  analysis  of  conditions 
is  necessary.  Frequently,  the  sufficiently  well-fed  appearance  of  children, 
who  are  brought  to  the  physician  because  of  loss  of  appetite,  proves  that  no 
anomaly  is  present,  but  rather  that  the  parents  expect  the  children  to  eat 
too  much.  In  other  instances,  children  eat  little  because  they  are  forced  to 
drink  large  quantities  of  milk,  which  reduces  the  appetite  for  other  food- 
The  anorexia  disappears  so  soon  as  milk  is  discontinued.  A  monotonous 
or  an  unbalanced  dietary  may  have  been  given  and  its  substitution  by 
appetizing  and  varied  meals,  consisting  of  green  vegetables,  coarse  bread, 
fruit,  cabbage,  etc.,  produces  wonderful  results.  Such  children  may  take 
too  little  exercise  or  not  get  enough  fresh  air.  In  true  nervous  anorexia, 
these,  causes  do  not  obtain,  but  there  appears  to  be  an  actual  absence  of 
appetite  or  of  the  sensation  of  hunger,  frequently  seen  even  in  infancy,  when 
only  with  great  difficulty,  can  enough  food  be  given  the  infant  to  maintain 
growth.  In  older  children,  the  amount  of  food  taken  may  be  small  gener- 
ally or  the  appetite  may  be  capricious  and  certain  foods  only  may  be  taken; 
while  others,  quite  similar,  are  refused.  With  many  of  these  cases,  the  gen- 
eral nutritive  condition  is  so  good  that  no  noticeable  deficiency  in  the  caloric 
supply  can  exist.  Only  exceptional  cases  occur,  in  which  so  strong  an 
aversion  to  all  forms  of  food  exists,  that  serious  inanition  results.  Doubtless 
these  are  always  based  upon  a  status  hystericus. 

In  a  certain  percentage  of  cases,  the  loss  of  appetite  seems  to  be  con- 
nected with  a  disturbance  of  mastication  and  resulting  difficulty  in  eating 
solid  foocL  At  times  it  appears  that  certain  foods  actually  produce  nausea 
because  they  suggest  some  perverse  association. 

The  probability  of  a  nervous  foundation  for  the  condition  is  indicated  by 
negative  gastric  findings.  A  degree  of  motor  insufficiency  may  be  present, 
or  some  hypoacidity  with  slight  hypotonia,  existing  as  part  of  a  frequent 
general  ptosis.  With  the  anorexia,  it  is  usually  possible  to  demonstrate 
other  nervous  symptoms,  e.  g.,  the  facialis  phenomenon,  vasomotor  irrita- 
bility, ready  exhaustion  and  psychopathic  tendency,  etc.  Upon  close 
inquiry  into  the  family  history,  f amilial  neuropathy  and  mental  inefficiency 
can  usually  be  established.  Such  a  relation  fails  to  explain,  of  course,  -the 
ultimate  processes  which  actually  cause  the  reduced  appetite. 

The  treatment  of  those  forms  of  anorexia  that  are  caused  by  an  im- 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  329 

proper  dietary  offer  no  difficulties.  A  rational  and  balanced  dietary,  varied 
as  much  as  possible,  reduction  of  milk  to  a  minimum,  and  regulation  of  the 
child 's  general  hygiene  bring  good  results.  In  the  true  nervous  form,  these 
measures  are  only  preparatory  to  the  real  treatment,  which  lies  in  the 
exercise  of  a  proper  pedagogic  influence.  If  the  environment  is  such  as  to 
make  it  advisable,  the  most  radical,  but  satisfactory  method  is  to  remove 
the  child  from  its  parents  and  to  find  for  it  a  home  with  sensible  people 
and  intercourse  with  normal  healthy  children.  Frequently,  a  quiet  but 
energetic  nurse  or  governess  may  accomplish  much,  if  she  has  such  full 
control  that  her  orders  are  not  countermanded  by  the  parents.  Treatment 
in  sanatoria  is  not  recommended,  for  pedagogic  reasons,  unless  serious 
psychic  disturbance  is  involved  cr  a  severe  degree  of  inanition  has  resulted 
from  the  hysterical  refusal  of  food.  Only  in  the  latter  event  are  we  justified 
in  attempting  forced  feeding,  entirely  unnecessary  in  other  cases  and,  as  a 
rule,  wholly  without  results. 

We  cannot  expect  by  any  method  we  employ  to  recover  a  normal 
appetite.  We  must  be  satisfied  if  the  child  obediently  takes  the  necessary 
quantities  of  food  without  resistance  or  show  of  caprice.  Gastric  treatment, 
often  presented  by  stomach  specialists,  is  useless.  Medicinally,  we  may 
use,  besides  pepsin  and  orexine  tannate,  strychnine  [tr.  nux  vomica,  grams 
2-5.0  (15-30  minims),  tr.  rhei  vin,  grams  20.0  (5  drams);  ten  drops  of  this 
mixture  in  orange  juice  twice  daily,  a  short  time  before  meals].  In  mild 
and  even  in  somewhat  severe  cases  spontaneous  recovery  may  be  expected 
at  puberty. 

OBSTRUCTION  OF  THE  INTESTINAL  CANAL 
CONGENITAL  INTESTINAL  STENOSIS 

Congenital  intestinal  occlusion  has  certain  points  of  election;  immedi- 
ately above  or  immediately  below  the  papilla  of  vater,  at  the  duodeno- 
jejunal  junction,  or  just  above  the  ca3cum.  It  occurs  less  frequently  in 
other  portions  of  the  small  intestine  or  the  colon.  The  obstruction  is 
caused  by  a  membranous  septum  or  by  scar-tissue,  or  by  the  existence  of 
long  imperforate  loops  of  the  intestine.  Extensive  portions  of  the  intestine 
may  even  be  absent.  Constriction  by  bands,  diverticulae  or  compression 
tumors  may  occur.  At  times,  multiple  obstructions  are  present,  when 
other  external  and  internal  malformations  are  often  observed.  The  forma- 
tion of  intestinal  atresias  is  probably  due  to  the  temporary  closure  of  the 
intestinal  canal,  which  is  normally  well-formed  and  patent  between  the 
fifth  and  tenth  week  of  fetal  life,  a  closure  which,  in  rare  or  exceptional 
cases,  persists. 

The  diagnosis  of  atresia  is  made  upon  the  occurrence  of  vomiting  imme- 
diately after  birth,  upon  the  absence  of  stools  containing  fecal  matter  and 
other  symptoms  of  ileus.  Most  of  these  cases  die  during  the  first  or  second 
week;  only  occasionally  do  they  live  longer.  From  the  nature  of  the  ob- 
struction, it  is  clear  that  only  in  exceptional  cases  may  results  be  expected 
from  surgical  interference. 


330  TEXT-BOOK  OF  PEDIATRICS 

The  prognosis  of  congenital  occlusions  of  the  rectum  or  the  anus  is 
more  favorable.  Operations  have  proved  successful  in  about  one-third  of 
these  cases. 

In  rare  instances,  we  have  to  deal,  not  with  complete  atresia,  but  with  a 
reduction  of  the  calibre  of  the  intestine,  the  symptoms  of  which  resemble 
those  of  chronic  acquired  ileus. 

DILATATION  AND  HYPERTROPHY  OF  THE  COLON 

(HlRSCHSPRUNG  's  DISEASE) 

This  term  is  applied  to  a  disease  that  may  be  demonstrated  clinically 
immediately  after  birth  or,  at  least,  in  early  infancy,  and  is  characterized  by 
the  extreme  dilatation  and  longitudinal  extension  of  all  or  a  part  of  the 
colon,  with  marked  hypertrophy  of  its  musculature.  The  ordinary  ana- 
tomic findings  resulting  from  intestinal  obstruction  are  not  present. 

This  anomaly  may  be  due  to  various  causes.  Possibly  a  congenital 
megacolon,  a  primary  congenital  malformation  comparable  to  congenital 


FIG.  98. — Eighteen-month-old  boy  with  dilatation  and  hypertrophy  of  colon  (Hirschsprung's 
disease).     (Prof.  Finklestein.) 

dilatation  of  the  esophagus,  may  exist.  This,  however,  is  a  very  rare  con- 
dition. More  commonly  we  find  obstruction  due  to  a  valvular  mechanism, 
which  can  be  demonstrated  only  by  a  very  careful  topographic  examination. 

Normally  in  the  infant  the  sigmoid  flexure  is  relatively  longer  than  in 
the  adult.  Occasionally  it  is  so  long  that  several  loops  are  formed.  It  will 
be  readily  seen  that  scybalse  and  a  large  volume  of  gas  may  gather  in  these 
loops,  and  cause  them  to  become  twisted.  If  this  be  long  continued  or 
frequently  repeated,  the  loops  gradually  become  dilated  and  later  show 
compensatory  hypertrophy. 

In  other  cases  the  cause  is  to  be  found  in  the  rectum  or  anus,  provoked 
either  by  spasm  of  idiopathic  or  fissural  origin,  by  a  simple  coprostasis 
which  has  been  neglected,  or  by  a  paralysis  of  the  lower  section  of  the 
bowel,  with  consequent  constipation. 

Intestinal  dilation  due  to  congenital  or  acquired  circular  stenosis  of  the 
lower  section  of  the  colon  is  differentiated  from  Hirschsprung's  disease  by 
the  existence  of  readily  recognized  obstruction. 

The  first  indications  of  the  disease,  which  may  appear  during  the  first 
few  days  of  life,  are  distention  of  the  abdomen  and  obstinate  constipation 
(Fig.  98).  For  a  time,  these  are  the  most  noticeable  symptoms.  Usually 


331 

the  circumference  of  the  hugely  distended  loops  of  the  colon,  which  con- 
tract forcibly  from  time  to  time,  can  be  made  out.  The  "dough  phenome- 
non of  Gersuny"  in  the  fecal  mass  can  frequently  be  demonstrated. 

The  anomaly  and  its  results  may  be  borne  without  much  discomfort 
for  a  time,  but  serious  symptoms  soon  appear.  Attacks  of  ileus  are  charac- 
teristic, with  colic,  vomiting,  and  collapse;  or,  again,  we  may  occasionally 
have  foul-smelling  diarrhoeic  stools  containing  blood  or  pus.  Death  results 
from  peritonitis  or  exhaustion,  incident  to  the  attacks  of  ileus,  and  usually 
in  early  childhood.  But  few  such  children  live  to  be  more  than  ten  years  old. 

Treatment  consists  in  the  removal  of  fecal  masses  and  the  prevention 
of  their  renewed  formation.  Enemata  are  most  useful  for  this  purpose, 
while  cathartics  are  hazardous.  Meteorism  may  be  prevented  by  placing 
a  drainage  tube  in  the  rectum,  the  tube  being  forced  above  the  valve  or 
kink.  With  continuous  treatment  satisfactory  results  may  be  obtained. 


FIG.  99. — Hirschspi ung's  disease  in  an  infant. 

If  this  method  is  not  successful,  if  the  attacks  of  ileus  become  frequent  or  if 
ulcerative  colitis  occurs,  surgical  interference  may  be  of  assistance. 

CONSTIPATION 

The  diagnosis  of  purely  functional  constipation  may  be  made,  even  in 
children,  only  after  a  careful  exclusion  of  all  other  possible  conditions  of 
disease,  which  might  lead  to  the  retention  of  feces,  (e.g.,  abdominal  or 
pelvic  tumors,  paralysis,  strictures;  constitutional  anomalies,  such  as 
myxedema,  idiocy,  etc.).  Cases  which  are  not  traceable  to  any  of  these 
causes  must  still  be  considered  from  many  and  various  points  of  view. 

The  constipation  of  breast-fed  infants  is  due  in  some  cases  to  insuffi- 
cient quantities  of  food  and  is  relieved  by  their  increase.  This  is  especially 
true  of  children  who  are  being  fed  from  a  breast  yielding  but  little  milk,  who 
are  in  a  condition  of  actual  underfeeding,  and  who  are  not  gaining,  or  are 
even  losing  weight.  Even  with  normally  developing  children,  whose  weight 
before  and  after  feeding  shows  that  they  are  receiving  sufficient  quantities, 
there  may  still  be  a  relative  insufficiency.  In  these  cases,  the  milk  is  so 
completely  absorbed  in  the  upper  part  of  the  alimentary  canal  that  there  is 


332  TEXT-BOOK  OF  PEDIATRICS 

no  material  for  fermentation,  which  causing  an  acid  reaction  stimulates, 
peristalsis.  These  forms  of  constipation  are  best  relieved  by  giving  thick 
gruels  made  of  coarse  cereals  or  oatmeal.  After  the  sixth  month,  the  con- 
dition indicates  the  necessity  of  adding  vegetables  to  the  diet.  Cathartics 
or  enemata  should  be  used  only  in  cases  with  a  long  sigmoid  flexure  as 
described  below. 

The  constipation  of  artifically-f ed  infants  is  usually  the  consequence  of 
a  faulty  diet.  In  younger  children,  exclusive  milk  feeding  plays  the  most 
important  role  and  a  reduction  of  milk  with  the  addition  to  the  diet  of 
vegetable  (flour)  foods,  or  of  large  quantities  of  malt  soup  extract,  bring 
about  an  improvement.  In  the  second  and  third  year  of  life  too  long 
continued  absence  of  solid  food  is  a  large  factor. 

Constipation  of  older  children  is,  in  many  cases,  due  to  an  excessive 
meat  diet,  which,  as  in  the  breast-fed  child,  gives  too  little  material  for 
fermentation  in  the  colon.  A  reduction  of  meat  and  fish,  eggs,  cheese  and 
milk,  with  an  increase  of  vegetable  foods,  especially  in  the  form  of  coarse 
breads,  unstrained  vegetables  containing  large  amounts  of  cellulose,  fruit, 
lettuce,  e.tc.,  or  with  the  feeding  of  large  amounts  of  fat,  will  prove  useful. 
As  an  aid  in  the  production  of  free  catharsis,  lemonade,  sweetened  with  large 
amounts  of  milk-sugar,  and  taken  cold  upon  an  empty  stomach,  or  sour 
grape  juice,  may  be  recommended. 

If  results  are  not  secured  by  these  methods,  we  must  consider  whether 
the  pressure  of  the  abdominal  musculature  is  properly  applied.  Very 
many  children  and  especially  young  children  do  not  know  how  to  use,  while 
some  do  not  take  the  trouble  to  use,  their  abdominal  muscles.  It  is  possible 
that  not  infrequently  there  may  be  a  disturbance  of  the  complicated  reflex 
mechanism  of  defecation,  due  to  errors  in  the  formation  of  habit,  to  fear  of 
pain,  etc.  It  is  probable  that  such  a  condition  exists  when  it  is  found,  upon 
rectal  examination,  that  fecal  masses  accumulates  immediately  behind  the 
sphincter.  Careful  education  alone  can  bring  certain  relief  to  these  children. 
Many  cases  of  obstinate  constipation  are  cured  in  a  short  time  by  a  change 
of  the  nurse,  by  strict  prohibition  of  cathartics  and  enemata,  or  by  cor- 
recting the  conscious  neglect  of  the  act.  Results  are  sometimes  obtained  by 
a  change  in  the  surroundings  of  the  child.  At  first,  it  is  often  necessary  to 
help  the  child  by  some  anti-obstructive  measures,  such  as  the  old  fashioned 
sulphur  treatment  (sulphur,  milk-sugar,  aa  5ss,  once  or  twice  a  day), 
which  prevents  the  formation  of  hard  scybala3. 

In  exceptional  cases,  the  cause  of  difficult  defecation  is  to  be  found  in 
the  existence  of  fissures,  or  in  the  recurrence  of  painful  spasms  of  the  anal- 
sphincter,  upon  the  removal  of  which  constipation  disappears. 

The  diagnosis  of  essential  obstipation,  based  upon  peculiar  anatomic 
and  functional  conditions,  may  be  made  when  all  the  methods  of  treatment 
discussed  above  have  failed.  The  long  sigmoid  flexure,  already  referred  to, 
causing  a  condition  resembling  Hirschsprung's  disease,  comes  in  for  con- 
sideration. Again  the  condition  may  be  but  a  single  manifestation  of  a 
general  ptosis,  expressed  in  the  atony  of  the  colon.  It  may  be  due  to  a 
relative  insufficiency  of  the  motor  mechanisms  of  the  bowel,  as  a  result 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  333 

of  which  variations  of  motility  occur.  In  these  cases  only,  are  we  justified 
in  using  massage,  oil,  and  cathartics.  Of  the  latter,  the  milder  infusions, 
[frangula  15.0  grams  (^  ounce),  boiled  with  250  c.  c.  (8  ounces)  water,  for 
fifteen  minutes],  or  tamarind,  aloin  pills,  and  rhubarb  are  used.  Treatment 
for  the  improvement  of  the  general  health  and  exercise  of  the  abdominal 
muscles,  etc.,  should  be  employed. 

INTUSSUSCEPTION 

While  other  forms  of  intestinal  occlusion  (volvulus,  strangulation  ob- 
struction by  adhesions  or  by  compression),  occur  during  childhood,  they 
are  relatively  rare  as  compared  with  intussusception.  About  one-half 
of  the  cases  are  recorded  in  infancy,  one-fourth  in  the  first  fourteen  years 
of  life,  and  the  other  fourth  in  older  persons. 

Intussusception  is  the  involution  of  a  portion  of  the  intestine,  the  intus- 
susceptum, into  a  lower  part,  the  intussuscipiens.  The  mesenteric  attach- 
ment and  its  vessels  are  dragged  into  the  layers.  There  are  four  common 
forms,  ileal,  ileocsecal,  ileocolic  and  colic;  the  second  form,  the  involution 
of  the  ileum  into  the  caecum,  is  by  far  the  most  frequent. 

The  mechanism  of  intussusception  is  as  follows:  a  portion  of  the  intes- 
tine, in  which  there  is  very  active  peristalsis,  forces  its  way  into  a  portion 
in  which  the  peristalsis  is  inhibited.  This  may  occur  physiologically.  The 
condition  becomes  pathologic  when  the  upper  part  is  imprisoned  and  sub- 
sequent changes  occur  in  it  and  its  mesentery.  It  is  not  easy  to  deter- 
mine either  the  cause  of  the  reduced  peristalsis  in  the  lower  segment,  or  of 
the  failure  of  its  physiologic  return.  In  some  cases,  traumata,  play  a  part ; 
in  others,  it  may  be  a  question  of  local  meteorism  or  of  peculiarities  in  the 
mesenteric  attachment.  More  appreciable  causes  are  the  presence  of  a 
polyp,  of  an  epiploic  appendage,  or  a  foreign  body  attached  to  the  entering 
point  of  intussusceptum.  No  satisfactory  explanation  has  been  found  for 
the  frequency  of  the  condition  in  childhood.  The  suggestion  of  an  excessive 
peristalsis  is  not  very  satisfying.  In  a  certain  number  of  rarer  cases,  the 
invaginated  portion  does  not  show  any  signs  of  injury  for  quite  a  long  time. 
Usually,  however,  the  obstruction  of  the  mesenteric  vessels  produces  venous 
congestion,  edema,  hemorrhage  and,  later,  gangrene  of  the  intussusceptum, 
with  local  or  general  peritonitis  or  general  septic  infection. 

Extremely  acute  cases,  ending  fatally  on  the  first  or  second  day,  are  seen. 
An  acute  or  subacute  course,  of  from  two  to  seven  or  even  fourteen  days 
duration,  is  more  common.  The  chronic  forms  are  rare. 

Symptoms. — The  symptoms  of  the  acute  type  are  as  follows:  Sudden 
onset  of  pain,  frequently  of  a  very  severe  nature ;  vomiting,  first  of  gastric 
and,  later,  of  intestinal  contents;  mucous  and  bloody  diarrhoea,  which  often 
occurs  with  severe  tenesmus,  but  which  may  be  absent  if  the  lesion  is  in  the 
upper  portion  of  the  intestine.  Sometimes  the  general  condition  is  only 
slightly  disturbed  for  a  time,  while,  in  others,  serious  shock  occurs  at  the 
very  beginning.  It  is  usually  the  increased  peristalsis  and  painful  hardening 
of  the  involved  segment  which  attracts  attention  to  the  obstruction ;  while 
meteorism  may  not  at  first  be  prominent.  Occasionally,  free  passage  of  the 


334 


TEXT-BOOK  OF  PEDIATRICS 


bowels  is  observed,  but  bowel  movements  and  the  exit  of  gas  are  usually 
suspended.  In  three-fourths  of  the  cases  the  intussusception  itself  may  be 
palpated  as  a  U-shaped  sausage-like  tumor.  Commonly  it  is  found  on  the 
left  side  but  in  case  of  imagination  of  the  small  intestine  it  may  be  dis- 
covered in  other  parts  of  the  abdomen.  Extreme  distention  of  the 
abdomen  may  make  the  examination  difficult  and,  because  of  the  pain,  an 
anesthetic  may  be  necessary.  At  times,  the  intussusceptum  may  be  pal- 
pated in  the  rectum  or  may  even  protrude. 

Course. — The  younger  the  child,  the  more  rapid  the  course  of  the  disease. 
About  one-half  of  the  cases  in  infancy  die  during  the  first  three  days  and 
four-fifths  during  the  first  week.  The  mortality  of  untreated  cases  is 
eighty  per  cent.  The  causes  of  death  are  shock,  ileus,  peritonitis,  and  sepsis 
of  intestinal  origin.  Spontaneous  recovery,  by  sloughing  of  the  invagi- 


FIG.   100. — Intestinal  tumor  showing  through  intestinal  wall  in  intussusception. 

nated  portion  of  the  intestine  occurs  in  two  per  cent,  of  the  cases  in  children 
in  the  first  year  of  life,  and  in  six  per  cent,  between  the  second  and  fifth  year. 
In  later  life  it  is  more  common.  Even  this  event  does  not  always  escape 
severe  symptoms.  Many  patients  suffer  from  serious  peritonitis  or  septic 
thrombosis  during  or  after  the  sloughing,  and  girdle  strictures  may  remain 
and  subsequently  produce  ileus.  After  recovery,  whether  spontaneous  or 
by  interference,  relapses  are  not  infrequent. 

The  symptoms  of  the  very  rare  chronic  cases  are :  palpable  tumor,  pain 
and  the  signs  of  the  partial  obstruction  of  the  bowel.  The  anatomic  basis  of 
this  sequel  is  an  involution  resulting  in  comparatively  mild  changes  in  the 
intestine  and  in  the  mesenteric  vessels. 

Diagnosis. — With  careful  consideration  of  all  the  symptoms,  a  diag- 
nosis is  usually  made  readily.  Difficulties  may  be  encountered  in  its  differ- 
entiation from  hemorrhagic  gastro-enteritis  and  from  the  severe  intestinal 
hemorrhages  which  begin  with  the  colic-like  pains  of  purpura.  In  rare  cases, 
seemingly  typical  symptoms  of  intussusception  may  be  due  to  an  unsus- 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  335 

pected  volvulus  of  the  caecum  or  sigmoid.  If  blood-stained  stools  are  absent 
and  the  tumor  lies  at  McBurney's  point,  appendicitis  must  be  considered, 
a  disease,  however,  which  is  much  less  frequent  than  intussusception  during 
the  first  two  years  of  life. 

Treatment. — The  non-surgical  treatment  of  intussusception  consists  in  a 
reduction  by  massage  or  by  dilation  with  air  or  water.  The  first  method  is 
indicated  in  cases  where  the  tumor  is  palpable,.  It  must  be  done  very 
gently  as  in  the  replacement  of  a  hernia.  The  alternative  methods  are  use- 
ful only  when  the  lesion  is  in  the  lower  segment  of  the  bowel.  Any  of  them 
must  be  employed  early  to  give  results.  Hirschsprung  reports  over  seventy 
per  cent,  of  recoveries  in  cases  treated  within  twenty-four  hours  and  only 
thirty  per  cent,  in  those  in  which  the  condition  had  existed  longer.  An  objec- 
tion to  these  methods  lies  in  the  operator's  inability  to  control  the  apparent 
results;  the  disappearance  of  the  tumor  may  be  due  to  a  change  in  position. 
Moreover  recurrences  are  common  and  there  is  grave  danger  of  rupture. 
Under  any  circumstances,  these  methods,  safely  done  only  under  an 
anesthetic,  should  be  tried  but  once,  and  that  upon  the  operating  table; 
so  that  if  absolutely  certain  restitution  has  not  been  obtained,  a  laparotomy 
may  be  performed  immediately.  If  the  replacement  has  been  successful,  the 
patient  must  be  very  carefully  watched  for  a  reappearance  of  the  tumor  or 
of  the  spastic  intestine.  The  results  of  prompt  surgical  interference  within 
the  first  twenty-four  hours  are  very  satisfactory. 

PROLAPSE  OF  THE  RECTUM 

Symptoms. — Prolapse  of  the  lower  bowel  segments  resembles  intus- 
susception very  closely.  It  is  an  evagination  rather  than  an  invagination. 
It  may  include  only  the  mucous  membrane  or  a  greater  or  smaller  portion 
of  the  rectum  itself  (Fig.  101). 

Even  in  children  otherwise  well,  anal  prolapse  may  be  caused  by  exces- 
sive dilatation  of  the  sphincter  with  large  scybalae  and  under  excessive 
pressure  of  the  abdominal  muscles.  Rectal  prolapse,  on  the  contrary,  is 
always  caused  by  atony  of  the  perineal  muscles,  as  it  is  found  in  congenital 
ptosis  or  in  spinal  paralysis  (as  in  spina  bifida),  or  it  may  be  acquired  in  the 
course  of  chronic  disturbances  of  nutrition. 

While  in  anal  prolapse  only  the  mucous  membrane  is  extruded,  in  severe 
cases  of  rectal  prolapse  a  conical  mass,  10-14  cm.  (4-6  inches)  long,  swollen 
and  congested  because  of  the  compressed  veins,  may  be  found.  The  mass  is 
hyperemic  and  bleeds  readily;  it  is  usually  covered  with  pus  and  may  be 
ulcerated.  At  its  apex,  the  lumen  of  the  bowel  is  visible.  By  the  applica- 
tion of  cold  and  by  the  use  of  gauze,  the  mass  is  readily  replaced  but  usually 
reappears  immediately  or  after  a  short  time. 

Treatment. — While  the  prolapse  itself  is  not  dangerous,  it  offers  a  port 
of  entry  for  local  and  general  septic  infection  and  for  this  reason  it  should 
be  removed  as  soon  as  possible.  The  bowels  should  be  regulated  so  as  to 
avoid  constipation  or  to  relieve  existing  diarrhoea.  Further  extrusion  should 
be  prevented  if  possible,  for  this  purpose  adhesive  strips  being  applied  so  as 
to  compress  the  buttocks,  renewing  these  after  each  bowel  movement. 


336  TEXT-BOOK  OF  PEDIATRICS 

As  an  alternative  the  cylindrical  balloon  pessaries,  resting  upon  an  external 
plate,  may  be  tried.  In  milder  cases,  treatment  with  astringents,  the 
mucous  membrane  being  painted  with  a  one  per  cent,  solution  of  silver 
nitrate,  or  enemata  or  suppositories  of  tannin  or  aluminum  acetate  being 
employed,  may  give  relief.  These  remedies  have  little  or  no  effect  uponseverer 
cases.  In  these,  surgical  treatment  should  be  resorted  to;  as,  for  instance, 
by  imbedding  a  fine  silver  wire,  according  to  the  method  of  Thiersch,  or,  as 
recently  recommended,  implanting  a  ring  of  fascia  from  the  thigh.  The 
protrusion  however  is  often  forced  through  the  ring.  Lately  the  injection 
of  two  pillars  of  paraffin  into  the  perirectal  tissue,  or  their  insertion  by 
means  of  a  trocar,  has  been  suggested.  The  repeated  injection  of  alcohol 
into  the  surrounding  tissues  for  the  purpose  of  shrinkage  may  also  be 


. 

FIG.  101. — Prolapse  of  rectum  in  eighteen-month-old  boy. 

mentioned.  All  of  these  are  doubtful  methods,  including  that  of  amputa- 
tion, and  appear  unnecessary,  if  it  is  possible  to  improve  the  general  condi- 
tion and  to  relieve  the  atony  of  the  perineal  musculature  by  proper  diet. 
The  case  shown  in  Fig.  101  was  treated  in  this  manner  and  the  prolapse 
completely  disappeared  within  three  months,  the  child  gaining  rapidly 
after  recovery. 

HERNIAS 

Congenital  inguinal  hernia,  or  inguinal  hernia  appearing  shortly  after 
birth,  is  very  common,  especially  in  boys,  because  the  inguinal  canal  has 
not  closed  or  its  closure  is  incomplete,  the  vaginal  process  of  the  peritoneum 
persisting  for  a  long  time.  Accordingly,  the  sac  does  not  lie  beside  the 
testicle  as  in  acquired  hernia,  but  the  intestine  and  testicle  are  enclosed  in 
the  same  sac  of  peritoneum,  unless  the  lower  part  of  the  vaginal  process 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  337 

is  practically  obliterated  (funicular  vaginal  hernia).  By  the  second  year, 
the  number  of  inguinal  herniae  decreases.  Typical  acquired  herniae  are  com- 
paratively rare.  The  sac  containing  the  intestine  may,  in  girls,  include 
also  the  ovary.  Strangulation  is  comparatively  rare  in  children. 

The  greater  percentage  of  these  ruptures  may  be  cured  by  bandaging. 
Instead  of  the  usual  truss,  long  strands  of  soft  yarn  passing  around  the  thigh 
and  pelvis  and  knotted  over  the  ring,  are  practical  in  very  small  infants. 
Only  after  the  first  year,  when  the  rupture,  failing  to  heal,  becomes  larger, 
is  a  radical  operation  indicated. 

Umbilical  hernia,  or  hernia  through  the  linea  alba  above  the  umbilicus, 
hardly  ever  becomes  large.  Strangulations  are  exceptional.  Careful 
bandaging,  begun  early  and  applied  continuously,  usually  results  in  com- 
plete closure  during  the  first  six  months  or,  at  least,  reduces  the  opening  so 
that  the  intestine  may  no  longer  pass.  A  flat  button,  not  a  round  one, 
sewed  to  a  bandage  of  webbing  or  held  in  place  by  a  strip  of  adhesive,  may 
be  used.  The  best  results,  however,  are  obtained  by  the  use  of  several 
strips  of  adhesive,  overlapping  like  shingles,  which  hold  the  hernia  back 
under  two  longitudinal  folds  of  skin  over  the  umbilicus.  This  should  be 
renewed  whenever  it  becomes  loose. 

Diaphragmatic  Hernia. — 'The  passage  of  the  intestine  into  the  thoracic 
cavity  through  congenital  openings  in  the  diaphragm,  which  may  be  very 
large,  is  rare.  In  exceptional  cases,  the  hernia  is  so  great  that  only  the  liver 
and  stomach  remain  in  the  abdominal  cavity.  The  hernia  is  usually  found 
on  the  left  side,  because  the  liver  forms  a  barrier  on  the  right.  The  con- 
dition may  be  present  at  birth  or  may  occur  immediately  after  birth. 
The  symptoms  are  those  of  severe  asphyxia,  occurring  paroxysmally,  and  in 
many  cases  resulting  in  death  soon  after  birth.  Tympany  and  absence  of 
respiratory  sounds,  are  noted  on  the  affected  side  of  the  thorax  and  cardiac 
dulness  disappears  or  is  pushed  to  the  right.  The  retraction  of  the  abdomen 
is  characteristic.  In  some  cases,  the  condition  gives  no  premonitory  symp- 
toms but  develops  suddenly  with  evidences  of  internal  strangulation.  In 
the  new-born,  nothing  is  to  be  hoped  for  from  treatment ;  in  older  children 
only  very  extensive  operations,  involving  resection  of  ribs,  replacement  of 
the  hernial  content  and  closure  of  the  opening,  are  successful. 

ENTOZOA 

Ascaris  Lumbricoides  (round  worms,  resembling  the  angleworm). — 
The  female  may  be  30  to  40  cm.  (12-16  inches)  and  the  male  20-25  cm. 
(8-10  inches)  in  length.  They  may  be  found  singly  or  in  very  large  numbers, 
in  the  small  intestine,  where  they  deposit  their  eggs.  The  eggs,  which  are 
oval,  of  double  contour  and  surrounded  by  a  gelatinous,  fringed,  rough 
capsule  are  found  in  the  stools.  The  infection  occurs  by  means  of  food, 
or  by  contact  with  dirt  which  contains  the  eggs.  The  diagnosis  is  made 
when  a  worm  is  passed  or  by  the  presence  of  ova  in  the  stools,  demonstrated 
by  the  microscope.  Symptoms,  such  as  abdominal  pain,  nausea,  irritation 
22 


338  TEXT-BOOK  OF  PEDIATRICS 

and  unhealthy  appearance  of  the  skin  are  cited,  but  are  by  no  means  cer- 
tainly present.  In  rare  instances,  large  ball-like  masses  of  entangled  worms 
may  produce  symptoms  of  ileus,  or  the  worms  may  reach  the  stomach  and 
be  vomited.  They  have  been  known  to  reach  the  larynx  and  cause  asphyxia. 
A  purulent  cholangitis  due  to  the  irritation  of  the  ascaris  in  the  bile-duct, 
has  been  demonstrated.  In  treatment,  the  anthelmintic  in  general  use  is 
santonin,  given  twice  daily  0.25  gm.  (M-H2  gr.),  for  two  days,  in  conjunc- 
tion with  a  cathartic  (calomel  or  castor  oil) .  Larger  doses  of  santonin  may 
produce  poisoning. 

The  oxyuris  vermicularis  (pin-worms  or  thread  worms),  also  inhabit 
the  small  intestine,  and  resemble  a  fine  white  thread  in  color  and  appearance. 
The  male  is  3-4  cm.  (1-1^  inches)  long  and  the  female,  8-12  cm.  (3-5  inches). 
The  sexually  mature  female  passes  into  the  large  intestine  or  out  of  the 
body  and  deposits  oval  eggs.  The  infection  is  carried  by  dirt  adhering  to 
the  fingers  or  by  food.  From  the  feces,  the  eggs  are  again  carried  to  the 
mouth  by  the  fingers  and  with  the  food  into  the  intestine,  which  is  the  cause 
of  the  obstinacy  of  the  infection.  Itching  around  the  anus  is  the  most 
important  symptom.  This  may  become  very  severe  whenever  a  new  group 
of  worms  passes  into  the  colon.  The  diagnosis  is  established  by  the  finding 
of  worms  in  the  stools.  When  worms  are  suspected,  inspection  of  the  anus, 
the  passage  of  a  catheter  into  the  bowel,  or  an  enema  will  produce  the  worms 
more  readily  than  an  examination  of  the  stools.  The  ova  are  found  more 
readily  by  microscopic  examination  of  the  material  scraped  from  the  skin 
surrounding  the  anus  than  in  the  feces. 

The  worms  are  removed  by  the  use  of  cathartics  and  enemata,  the  best 
results  being  obtained  with  a  five  days'  treatment.  The  first  day,  with  a 
light  diet,  a  cathartic  is  given  in  the  afternoon,  followed  in  an  hour  by  a  soap 
enema;  the  second  day,  no  food  is  given  and  santonin  is  administered  two  or 
three  times  at  two  hour  intervals,  with  again  a  cathartic  in  the  afternoon;  on 
the  third  to  the  fifth  day,  a  warm  daily  bath  and  soap  enemata,  twice  daily, 
are  given.  During  this  time  and  afterwards,  reinfection  must  be  prevented 
by  cleanliness  of  the  hands,  finger-nails  and  anus.  The  stools  should  be 
disinfected.  Naphthalin  treatment  0.3-0.4  grams  (6  grs.),  threeror  four  times 
daily,  for  two  days,  repeated  in  two  weeks,  is  recommended.  Fats  must  be 
avoided  during  treatment.  The  other  members  of  the  family  should  be 
examined  and,  if  necessary,  treated.  Usually,  there  are  several  persons  in- 
fected in  the  same  family,  which  makes  the  results  of  treatment  of  only 
one  member  doubtful. 

Tenia  saginata  is  the  most  common  of  tape-worms.  The  treatment  of 
the  infection  is  the  same  as  in  adults,  with  fluid  extract  of  aspidium  0.5 
c.c.  (5  minims)  for  each  year  of  age,  up  to  4.0  c.c.  (1  dram)  with  equal  parts  of 
powdered  senna  leaves  and  powdered  tamarind  bark.  Older  children  may 
be  given  the  remedy  in  gelatin  capsules.  Rest  in  bed  is  advantageous  in 
all  treatment  of  tape-worm  and  it  is  well  to  rest  the  intestine  after  complete 
removal  of  the  parasite. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  339 

DISEASES  OF  THE  LIVER 
CATARRHAL  JAUNDICE 

The  most  common  disease  of  the  liver  in  childhood,  catarrhal  icterus, 
usually  occurs  in  epidemic  groups  and  in  children  over  two  years  of  age.  It 
is  hardly  ever  seen  in  infants.  This  gives  some  indication  of  the  etiology, 
of  which  nothing  further  is  known.  The  disease  usually  has  an  acute  onset, 
with  slight  or  high  fever  and  occasionally  gastro-intestinal  symptoms. 
The  jaundice  appears  after  the  second  or  third  day  with  coincident  changes 
in  the  urine  and  white  acholic  stools.  The  liver  and  spleen  may  be  swollen 
and  itching  of  the  skin  may  be  noted.  In  older  children,  a  reduction  of  the 
pulse-rate  is  demonstrable.  The  tongue  is  coated  and  the  appetite  poor. 
The  course  is,  as  a  rule,  short.  The  fever  disappears  after  several  days  and 
within  one  to  two  weeks  complete  recovery  is  made.  Only  exceptionally, 
and  for  some  unknown  reason,  does  the  icterus  continue.  Rare  cases 
with  cholemic  symptoms  and  acute  atrophy  of  the  liver  have  been  observed. 

Treatment. — The  diet  forms  the  most  important  part  of  the  treatment. 
Considering  the  absence  of  bile,  it  is  customaiy  to  give  food  as  free  from  fat 
as  possible;  that  is,  a  diet  consisting  chiefly  of  carbohydrates  (flour  soup, 
rice,  gruels,  etc.).  Skim-milk  or  buttermilk,  vegetables,  fruit  stewed  or  raw, 
and  finely  divided,  may  be  added.  Protein  is  preferably  given  in  the  form 
of  skim-milk  or  cheese,  rather  than  as  meat  and  fish.  The  usual  constipa- 
tion should  be  overcome  by  mild  cathartics  (rhubarb,  or  Rochelle  salts). 
Mild  laxative  teas  and  aperient  waters  may  be  tried.  If  the  case  is  of  long 
duration,  high  enemata  of  Karlsbad  water  may  be  advised.  Small  doses  of 
calomel,  combined  with  podophyllin  [calomel  0.0025-0.005  gram  (Mo-Mo 
gr.);  podophyllin  0.005-0.01  gram  (Mo-Vs  gr.)  two  or  three  times  a  day]  is 
also  very  useful.  To  increase  the  appetite,  various  bitter  tonics  may  be 
given  [tr.  rhei;  20.0  grams  (4  drams)  with  tr.  nucis  vomicce,  5.0  grams 
(1  dram)  ten  to  twenty  drops,  of  this  mixture  two  or  three  times  daily]. 

OTHER  FORMS  OF  ACUTE  JAUNDICE 

Other,  and  rarer  forms  of  acute  icterus  occur  in  childhood.  Weil's 
disease,  which  is  probably  due  to  infection  with  a  member  of  the  proteus 
group,  and  occurs  with  severe  general  symptoms,  high  fever,  tendency  to 
hemorrhage,  and  nephritis,  is  one  of  these.  Acute  yellow  atrophy,  liver 
abscess  with  sepsis,  appendicitis,  gastro-enteritis  and  hepatitis,  developing 
in  the  course  of  general  septic  disease,  are  complicated  with  jaundice. 
Gall-stone  disease  is  probably  extremely  rare. 

CIRRHOSIS  OF  THE  LIVER 

Syphilitic  Cirrhosis. — Cirrhosis  of  the  liver  is  most  common  in  infants 
during  the  first  months  of  life.  It  may  be  congenital  and,  in  this  event,  is 
doubtless  always  caused  by  syphilis.  We  distinguish  three  main  forms. 
The  most  common  is  the  diffuse  portal  cirrhosis,  which  arises  from  a  general 
portal  infiltration,  and  is  chiefly  characterized  by  marked  swelling  and 


340  TEXT-BOOK  OF  PEDIATRICS 

hardening,  with  or  without  slight  icterus,  and  enlargement  of  the  spleen. 
This  goes  on  to  granulation  and  shrinkage  of  the  liver  tissue,  with  ascites. 

The  knotty,  gummatous  form  is  also  seen;  and  finally,  the  icteric  cir- 
rhosis, probably  due  to  a  gummatous  cholangitis,  and  leading  to  marked 
enlargement  and  icterus.  All  of  these  forms  occur  also  in  later  life,  and 
although  actually  rare,  are  still  relatively  more  frequent  than  any  other 
types  of  cirrhosis. 

Of  these  other  forms,  occurring  even  in  two  and  three-year-old  children, 
alcoholic  cirrhosis  has  been  seen:  also,  cirrhosis,  with  tuberculous  perito- 
nitis and  rare  cases  of  the  hypertrophic  icteric  cirrhosis  of  Hanot,  of  uncertain 
origin,  have  been  reported.  Congestive  cirrhosis  with  enlargement  of  the 
liver  and  spleen,  with  ascites,  clinically  distinguished  from  other  forms  by  a 
marked  general  cyanosis,  is  somewhat  more  frequent.  The  cause  of  the 
congestive  feature,  as  of  its  cyanotic  result,  is  often,  but  not  always,  of  a 
pericardial  or  tuberculous  nature.  This  relationship  to  the  changes  seen  in 
the  liver  is  not  yet  clearly  understood. 

In  addition  to  simple  cirrhosis  of  the  liver  due  to  pericarditis,  the  type  of 
lardaceous  liver,  characterized  by  hard  cartilage- like  deposits  in  the  con- 
nective tissue,  may,  at  times,  develop  under  similar  cii  cumstances. 

Cirrhosis  of  the  liver  rarely  occurs  in  connection  with  general  infectious 
diseases  (e.  g.,  measles  or  scarlet  fever).  In  tropical  climates,  an  icteric 
cirrhosis,  in  connection  with  malaria  and  a  biliary  cirrhosis  of  unknown 
etiology  (the  so-called  infantile  liver),  have  been  observed. 

TUMORS  OF  THE  LIVER 

Among  various  tumors  of  the  liver,  the  very  malignant,  partially  dif- 
fused, infiltrating,  and  semi-tuberous  carcinoma  and  sarcoma,  must  be 
mentioned.  They  are  frequently  secondary  to  the  kidney  or  adrenal  affec- 
tion. Of  the  rare  primary  forms,  the  greater  part  may  be  traced  to  mis- 
placed germ  cells.  Operation  is  impossible.  In  diagnosis  they  must  be 
differentiated  from  gummata. 

Cystic  tumors  of  the  liver  are  congenital  or,  at  least,  may  be  traced  to  a 
congenital  matrix.  They  appear  either  as  solitary  tumors  or,  more  com- 
monly, as  multiple  cysts  in  the  liver  and  may  reach  a  great  size.  Finally 
the  echinococcus  cyst  has  been  observed  in  childhood. 

CONGENITAL  OBSTRUCTION  OF  THE  BILE  DUCTS 

Congenital  obstruction  of  the  large  bile  passages  is  a  rare  disease.  It  has 
its  origin  in  a  malformation,  consequent  upon  an  extensive  or  total  separa- 
tion of  the  germ  centre  of  the  liver  from  that  of  the  intestine,  as  a  result  of 
which  the  bile  passages  are  either  rudimentary  and  imperforate  or  are 
entirely  absent.  As  a  result  of  obstruction  to  the  flow  of  bile,  a  biliary  cir- 
rhosis is  formed  by  distention  of  the  bile  passages  and  hypertrophy  of  the 
connective  tissue.  The  malformation  may  exist  in  varying  degree.  Its 
most  serious  form  is  the  complete  absence  of  all  the  bile  passages ;  the  slight- 
est and  the  most  important  for  practical  purposes  is  a  simple  occlusion  of 
the  opening  of  the  bile-duct  into  the  intestine.  The  disease  is  in  no  way 
related  to  syphilis. 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  341 

Symptoms. — Children  with  this  malformation  are  born  with  icterus,  or 
become  icteric  after  a  very  few  days.  The  discoloration  gradually  reaches 
its  highest  possible  degree.  In  the  meantime,  the  liver  and  spleen  become 
large  and  hard.  The  urinary  findings  correspond  to  the  discoloration  of  the 
skin.  (The  stools  are  acholic  from  birth.) 

Course. — The  disease  ends  fatally  during  the  ninth  or  tenth  month, 
at  the  very  latest  (commonly  before  the  fourth  month),  often  with  cholemic 
symptoms  and  those  of  a  hemorrhagic  diathesis.  The  possibility  of  forming 
a  connection  between  the  biliaiy  system  and  the  bowel  obtains  only  in  cases 
of  atresia  of  the  papilla,  which,  of  course,  cannot  be  diagnosed,  and  are 
rare  as  compared  with  the  incurable  forms. 

In  older  children,  serious  and  long  sustained  cases  of  icterus,  due  to 
diseases  of  the  bile  passages,  such  as  congenital  stenosis  and  cystic  develop- 
ment, in  particular,  occur. 


PURULENT  PERITONITIS 

Purulent  Peritonitis  of  the  New-born. — The  greatest  prevalence  of  peri- 
toneal disease  is  found  in  the  new-born,  and  corresponds  with  the  large 
percentage  of  other  septic  infections  common  to  this  age.  Infections  extend- 
ing from  the  umbilical  vessels  are  most  common.  Next  in  frequency  are 
the  metastatic  infections  and,  finally,  infections  arising  in  the  thora.cic 
organs.  Peritonitis  in  infancy  from  other  causes,  and  especially  from  per- 
foration, is  rare.  The  diagnosis  is  very  difficult  at  this  age  because  the 
characteristic  symptoms  are  not  very  definite  and  meteorism,  vomiting  and 
sudden  loss  of  weight,  so  commonly  depend  upon  other  causes  than  perito- 
nitis. The  recognition  of  the  disease  is  of  much  less  importance  in  infants 
than  in  older  children,  because  the  age  of  the  patient  and  the  nature  of 
the  disorder  forbid  operative  interference. 

PERITONITIS  IN  OLDER  CHILDREN  FOLLOWING  APPENDICITIS 

Appendicitis  is  extremely  rare  in  the  first  year  of  life  and  is  observed  only 
exceptionally  during  the  second  year.  From  this  time  on,  however,  it 
rapidly  becomes  more  frequent,  together  with  secondary  peritonitis  incident 
to  it.  To  one  acquainted  with  the  disease  in  adults,  its  manifestations  in 
children  do  not  present  any  peculiarities.  The  diagnosis  is  made  difficult, 
however,  by  the  uncertainty  of  the  subjective  symptoms,  and  by  the  fre- 
quency of  other  intestinal  disturbances,  which  tend  to  lead  the  diagnosti- 
cian in  other  directions.  In  the  differential  diagnosis  we  must  consider, 
aside  from  acute  intestinal  catarrh  and  gastric  conditions  with  painful 
colic,  the  following  facts.  In  children,  with  separation  of  the  recti  and 
other  signs  of  ptosis,  attacks  of  severe  abdominal  pain  occasionally  occur 
and  are  relievable  by  properly  applied  bandages  or  adhesive  straps.  In 
their  onset,  diseases  of  the  respiratory  passages,  and  especially  pneu- 
monia, run  an  initial  course  attended  by  pain,  which  is  frequently  localized 


342  TEXT-BOOK  OF  PEDIATRICS 

by  the  child  in  the  lower  abdomen.  Similarly,  we  sometimes  find  in  influenza 
and  other  general  infections,  areas  of  hyperaesthesia  and  zones  of  head  in  this 
region.  In  childhood,  an  habitual  torsion  of  the  movable  caecum  is  common 
and  is  characterized  by  tumor,  pain,  and  occasional  diarrhoea  of  blood- 
stained stools.  In  chronic  fermentative  dyspepsia,  also  (q.  v.),  severe  pains 
and  local  tympany  are  observed. 

OTHER  FORMS  OF  PURULENT  PERITONITIS  IN  OLDER  CHILDREN 

Those  forms  of  peritonitis  which  do  not  arise  from  the  appendix  are 
comparatively  unimportant  in  older  children,  when  we  consider  that  those 
cases  which  may  be  regarded  as  purely  peritonitic  give  hope  of  remedy 
from  surgical  interference.  In  this  group,  are  included  peritonitis  from 
perforation  of  a  typhoid,  tuberculous,  duodenal  or  ventricular  ulcer; 
peritonitis  due  to  transmigration  in  enteritis  and  ileus;  and  peritonitis 
following  the  strangulation  of  a  hernia.  The  majority  of  cases  observed 
belong,  however,  to  a  group  arising  from  pulmonary  and  pleuritic  infections, 
or  to  the  type  of  metastatic  peritonites,  in  so  far  as  these  appear  as  primary 
localizations  of  an  infection,  or  even  as  an  apparently  primary  disease. 

Peritonitis  due  to  infection  with  pneumococcus  occurs  as  a  phase 
of  a  multiple  purulent  inflammation  of  the  serous  membranes  (Heubner's 
disease),  or  polyserositis,  polyorrhomenitis,  affecting  the  pleura,  menin- 
ges  and  joints,  which  is  seen  quite  frequently,  even  in  infants.  In  older  chil- 
dren it  is  of  greater  individual  importance  and  is,  therefore,  a  direct  object  of 
diagnosis  and  therapy.  The  pneumococcus  peritonitis  of  older  children, 
chiefly  affecting  girls,  although  no  definite  infection  from  the  genitals  can 
be  traced,  may  be  regarded  as  a  migratory  peritonitis  derived  from  the 
intestine  or  from  the  pleura.  Probably  most  cases  might  show  a  hemato- 
genous  origin  from  some  primary  focus,  as,  for  instance,  an  angina. 

The  disease  begins  suddenly  with  high  fever,  vomiting,  diarrhoea  and 
severe  abdominal  pains.  After  several  days  the  condition  improves  but 
the  diarrhoea  continues,  and  gradually  signs  develop  in  the  abdomen  which 
point  to  the  presence  of  an  exudate.  Distention,  dulness  and  possible 
fluctuation  are  observed.  The  dulness  is  usually  not  that  of  a  general 
exudation,  but  rather  resembles  that  of  a  large  walled-off  abscess  filled 
with  thin  pus,  containing  pneumococci.  Left  alone,  it  gradually  extrudes 
through  the  umbilicus  and  finally  ruptures  it.  Alternatives  of  rupture  into 
the  genitals,  the  colon  or  the  urinary  bladder  may  occur.  A  diffuse,  puru- 
lent peritonitiswithmovable  exudate  ismore  rare  than  the  encapsulated  form. 

The  diagnosis  is  difficult.  In  the  beginning,  appendicitis  is  usually 
suspected;  differential  signs,  viz.,  severe  diarrhoea,  localization  of  pain,  and 
absence  of  muscular  rigidity,  on  the  one  hand,  are  hardly  constant,  and,  on 
the  other,  scarcely  serve  as  a  sufficient  basis  for  differentiation.  In  its 
distinction  from  typhoid,  the  severe  pain  and  violent  vomiting  at  the  outset 
and  the  absence  of  leucopenia  are  valuable.  In  the  later  stages,  the  appear- 
ance of  an  exudate  is  distinctive.  With  the  large  quantity  of  exudate 
eventually  present,  tuberculous  peritonitis  might  be  suspected,  but  the 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  343 

acute  course  and  a  bacteriologic  examination  of  the  pus,  obtained  by  explor- 
atory puncture,  should  rule  this  out. 

Streptococcus  peritonitis  similarly  caused,  and  with  symptoms  similar 
to  those  described  above,  excepting  that  the  tendency  to  encapsulation  is 
wanting,  and  that  its  course  is  much  more  acute  and  more  malignant.  In 
bacterial  diagnosis,  not  only  the  pus,  but  the  venous  blood  obtained  by 
puncture  may  be  used. 

Gonococcus  Peritonitis. — In  girls  showing  a  gonorrheal  discharge 
circumscribed  pelvic  peritoneal  inflammations  are  occasionally  seen. 
These  occur  with  symptoms  similar  to  those  met  in  adults.  Exceptionally 
the  inflammatory  process  continues  for  weeks  with  high  fever  and  extends 
over  the  whole  abdomen.  This  is  distinguished  from  other  forms  of  peri- 
tonitis by  the  relatively  slight  effect  it  has  upon  the  general  condition. 
A  provisional  diagnosis  is  based  upon  the  presence  o'f  vulvo-vaginitis  and 
upon  the  demonstration,  by  rectal  examination,  of  a  major  genital  disease. 
It  should  be  remembered,  however,  that  a  child  with  vaginal  discharge 
may  have  a  coincidental  non-gonorrhoeal  peritonitis. 

The  disease  is  relatively  benign.  Even  the  diffuse  form  is  in  most  cases 
self-limited.  Cases  with  fatal  termination,  however,  are  known. 

The  treatment  of  purulent  peritonitis  in  childhood,  and  especially  its 
operative  treatment,  is  founded  upon  the  rules  applicable  to  adults.  In 
general,  the  earliest  possible  opening  of  the  abdomen  is  indicated.  Only 
in  gonorrhceal  peritonitis  may  spontaneous  recovery  be  expected.  In  the 
pneumococcus  peritonitis  it  is  of  advantage  to  operate  after  the  abscess  has 
been  encapsulated.  This  advice,  however,  which  can  hardly  be  followed  in 
cases  with  severe  symptoms  and  of  uncertain  etiology. 


TUBERCULOSIS  OF  THE  MESENTERIC  AND  RETROPERITONEAL  LYMPH  NODES 

As  tuberculous  infection  of  any  locality  produces  tuberculosis  of  the 
regional  lymph  nodes,  so  those  of  the  mesentery  and  of  the  retro  peritoneal 
spaces  may  become  diseased  from  a  tuberculous  lesion  in  the  intestinal 
mucosa,  which  may  be  completely  healed  while  the  secondary  process  in 
the  nodes  continues  and  spreads.  The  nodes  enlarge  and  caseate,  and 
extensive  confluent  lymph  tumors  £re  formed  by  adhesive  inflammation. 
The  mesentery  and  omentum  may  become  knotted  and  adherent  and  knob- 
like  granulation  tumors,  resembling  a  string  of  beads,  may  develop  in  the 
intestinal  serosa  and  in  the  mesentery.  Many  of  these  forms  are  pro- 
duced by  bacilli  of  the  bovine  type.  It  is  then  possible  to  palpate  multiple, 
cylindrical  and  nodular  masses  of  marked  resistance  in  the  abdomen.  The 
abdomen  is  distended  (Fig.  102),  and  usually  the  spleen  is  greatly  enlarged. 
The  process  is  insidious  beginning  with  indefinite  pains  and  later  giving 
high  and  often  hectic  fever.  Nutrition  is  seriously  affected  and  cachectic 
edema  is  common.  These  general  manifestations  may  continue  for  a 
long  time  before  findings  on  palpation  are  possible.  The  prognosis  is  un- 
favorable ;  but  recovery  occasionally  takes  place  even  in  severe  cases. 


344  TEXT-BOOK  OF  PEDIATRICS 

The  Adhesive  Form  of  Tuberculous  Peritonitis. — This  greatly  resembles 
the  form  just  described.  It  has  its  origin  in  a  tuberculous  infection  of  the 
peritoneum,  which  gradually  develops  from  crops  of  miliary  tubercles  to 
large  masses  of  diffuse,  scattered,  caseous,  granular  masses,  binding  loops  of 
intestine  together  by  adhesions.  Finally,  the  intestinal  loops  become  adher- 
ent to  each  other  and  to  the  parietal  peritoneum  in  an  inextricable  mass. 
The  caseous  masses  between  the  intestinal  loops  may  break  down  and  rup- 
ture into  the  bowel,  into  the  pelvic  organs,  or  even  externally.  The  abdom- 
inal cavity  may  become  infected  with  pus  organisms,  when  a  septic  and 
inhorous  infection  and  general  intoxication  are  added  to  the  tuberculosis. 

Symptoms. — Clinically,  the  disease  begins  with  languor  and  indefinite 
symptoms,  such  as  slight  abdominal  pain?  and  occasional  vomiting.  With 
these  there  may  be  a  slight  temperature.  The  abdomen  gradually  becomes 
irregularly  distended  and  is  hard  to  palpate.  Percussion  and  palpation 
lead  to  the  suspicion  of  tumors.  There  is  no  free  ascites.  As  the  disease 


FIG.  102. — Tuberculous  peritonitis.     (Gisela  Children's  Hospital,  Munich,  Prof.  Ibrahim.) 

goes  on  the  fever  continues;  and  diarrhoea  and  anorexia  considerably  reduce 
the  weight.  Occasionally  symptoms  of  partial  intestinal  obstruction  occur. 
The  situation  becomes  hopeless  if  the  softening  tubercles  become  infected  or 
rupture.  The  prognosis  is  the  same  as  in  abdominal  tuberculous  adenitis. 

The  Exudative  Form  of  Tuberculous  Peritonitis. — This  condition 
results  from  a  crop  of  miliary  or  sub-miliary  tubercles,  "which  do  not  caseate 
but  remain  in  the  stage  of  granulation  and  degenerate.  The  tubercles  are 
accompanied  by  a  serous  exudate,  of  which  several  litres  may  be  formed. 
This  type,  which  has  a  relatively  good  prognosis,  begins  insidiously,  with 
slight  temperature  and  mild  indications  of  abdominal  disturbance.  Later, 
the  abdomen  increases  in  size  and  the  presence  of  a  movable  exudate  be- 
comes definite.  The  patient 's  general  health  is  but  slightly  affected.  Hard, 
light-colored  stools  are  usual,  but  diarrhoea  may  be  present. 

A  large  percentage  of  these  cases  are  amenable  to  treatment,  even 
though  they  go  on  for  months  and  recurrences  or  exacerbations  occur. 

The  diagnosis  of  tuberculous  diseases  of  the  peritoneum  is  dependent 
upon  the  history  and  the  demonstration  of  other  accompanying  symptoms 
of  tuberculosis  (lichen  scrofulosum,  tuberculides,  lymph  nodes,  etc.). 


DISEASES  OF  THE  DIGESTIVE  SYSTEM  345 

Even  if  these  are  not  present,  tuberculosis  is  probable,  because  other 
peritoneal  diseases  are  more  rare  in  children.  The  abdominal  tumors  should 
not  be  mistaken  for  masses  of  fecal  matter.  Rectal  examination  may,  at 
times,  reveal  enlarged  nodes  high  in  the  abdominal  cavity  and  small 
nodular  irregularities  in  the  pouch  of  Douglas.  In  the  presence  of  large 
quantities  of  free  exudate,  diseases  of  the  liver,  heart  lesions,  and  pneumo- 
coccus  peritonitis  must  be  excluded.  In  these  cases,  a  bacteriologic  and 
cytologic  examination  of  the  fluid  obtainable  by  puncture  is  necessary.  A 
lymphocytosis  is  strongly  indicative  of  tuberculosis.  Bacteria  can  be 
demonstrated  only  in  the  centrifuged  material  or  by  injection  into  labora- 
tory animals.  Pseudo-ascites,  in  the  course  of  severe  chronic  digestive 
insufficiency,  may  be  recognized  by  close  observation  of  the  digestion,  by 
the  variation  in  its  quantity,  by  the  difference  in  the  areas  of  dulness, 
which  do  not  resemble  those  of  a  free  general  exudate,  and  by  examination 
of  the  fluid  obtained  by  puncture. 

In  the  treatment  of  all  forms  of  tuberculosis  of  the  peritoneum,  the 
hygienic  and  climatic  factors,  indicated  in  all  forms  of  tuberculosis,  should 
receive  first  consideration.  To  these  are  to  be  added  methods  which  will 
increase  local  absorptions;  i.  e.,  heat  in  all  forms  (hot  applications,  electric 
pads  and  local  electric  light  baths),  and  action  of  the  sun's  rays  upon  the 
abdomen.  The  exposure  to  the  sun  should  last  only  for  a  few  minutes  at 
first  and  the  time  should  be  gradually  lengthened.  In  mountain  resorts 
and  at  the  seaside,  these  sun-baths  may  produce  surprising  cures;  while  in 
advanced  cases  they  may  cause  serious  recurrences  and  even  fail  entirely. 
Soft  soap  treatments  and  salt  may  be  useful  (see  scrofula) .  In  many  cases 
the  resorption  of  the  exudate  seems  to  be  hastened  by  a  salt-free  diet.  A 
generous  mixed  diet  should  be  allowed,  but  actual  overfeeding  must  be 
avoided.  Diarrhoea  should  be  treated  according  to  the  methods  described 
for  intestinal  catarrh.  Medicinally,  the  treatment  is  that  recommended 
for  scrofula  and  general  tuberculosis.  Iodine  is  especially  useful. 

The  value  of  surgical  treatment  has  probably  been  overestimated.  Its 
best  results  are  seen  in  forms  associated  with  ascites,  in  which  fairly  good 
results  may  also  be  obtained  by  the  methods  of  internal  medicine.  Nor 
does  operation  promise  much  in  other  forms.  It  is  of  chief  use  in  children 
for  whom  a  physical,  dietetic,  and  climatic  method  cannot  be  applied, 
because  of  surrounding  influences.  Opening  of  the  abdomen  and  removal 
of  fluid  is  sufficient;  sometimes,  simple  puncture  is  effectual. 

FETAL  PERITONITIS 

At  autopsies  on  the  still-born  or  on  children  who  have  died  immediately 
after  birth,  the  residue  of  a  fetal,  aseptic  peritonitis  is  found  in  the  form  of 
adhesions  and  bands  of  connective  tissue.  Such  children,  may  live  and 
show  symptoms  of  intestinal  obstruction  from  birth.  Fetal  peritonitis 
may  be  the  result  of  a  malformation  of  the  intestinal  tract  or  the  genital 
apparatus;  of  the  passage  of  the  fetal  intestinal  contents  through  a  perfor- 
ation into  the  abdominal  cavity;  or  it  may  be  due  to  the  placental  trans- 


346  TEXT-BOOK  OF  PEDIATRICS 

mission  of  substances  producing  inflammation.    Syphilis  may  be  considered 
as  a  causative  factor  in  a  number  of  cases. 

Syphilitic  peritonitis,  with  pseudomembranous  exudation  is  no  uncom- 
mon symptom  of  the  first  irruption  of  the  disease  in  the  infant.  In  ex- 
ceptional cases,  it  produces  typical  symptoms  of  peritonitis,  vomiting, 
meteorism,  and  ileus  due  to  scar-formation  and  kinking. 

TUMORS 

Among  benign  tumors  of  the  peritoneum,  simple  cysts,  echinococcus, 
fetal  inclusions  and  dermoid  cysts,  may  be  mentioned;  among  the  malig- 
nant, medullary  carcinoma  and  sarcoma.  The  symptoms  of  the  latter 
resemble  the  tumor-forming  and  exudative  tuberculous  peritonitis. 


IV. 
DISEASES  OF  THE  RESPIRATORY  ORGANS 

BY 

C.  FRH.  VON  PIRQUET, 

Vienna. 

REVISED  AND  EDITED  BY 

WALTER  H.  O.  HOFFMANN,  M.  D., 

Associate  Attending  Physician  Children's  Memorial  Hospital,  Chicago. 


THE  child 's  nose  is  not  only  absolutely,  but  also  relatively,  smaller  than 
that  of  the  adult.  Its  development  does  not  keep  pace  with  that  of  the 
cranium,  but  rather  with  that  of  the  extremities;  and  in  consequence  it  is 
coincidently  and  characteristically  involved  in  those  disturbances  of 
development  which  may  be  distinctly  demonstrated  in  the  long  bones.  This 
delay  in  development  results  in  a  prolonged  arrest  of  growth,  or  in  the  per- 
petuation of  a  phase  resembling  the  embryonic  snub-nose. 

The  nose  remains  particularly  sma,ll  in  achondroplasia  or  true  dwarfism. 
A  deep  saddle  lies  under  the  prominent  forehead,  and  beneath  this  is  only  a 
slight  nasal  prominence.  Similarly  in  myxedema,  the  nose  is  affected, 
together  with  the  rest  of  the  body,  but  to  a  less  extent  than  in  rickets. 

The  small  nose  in  congenital  lues  probably  cannot  be  charged  to  a 
delay  in  the  bony  growth,  but  is  rather  a  local  process  of  a  chronic  inflam- 
mation of  the  nasal  mucous  membrane  and  the  bony  framework  of  the  nose. 

In  the  healthy  child,  the  nose  is  the  exclusive  passageway  for  the 
respired  air.  Mouth  breathing  is  always  a  sign  that  the  nose  is  not  nor- 
mally patent.  Small  children  do  not  open  the  mouth  even  in  very  forced 
respiration.  When  the  auxiliary  respiratory  muscles  of  the  thorax  are 
called  into  play,  the  movements  of  the  aloe  nasi  become  visible.  When  this 
is  associated  with  an  expiratory  grunt,  it  is  an  almost  certain  diagnostic 
sign  of  pneumonia. 

RHINITIS;  CORYZA 

The  nares  act  as  a  filter  for  the  respired  air.  Their  moist  mucous 
membrane,  covered  by  ciliated  epithelium,  serves  very  effectively  for 
removing  particles  of  dust  and  soot  and  other  gross  physical  impurities 
from  the  atmosphere.  Most  of  the  micro-organisms  which  appear  in  the 
nares  are  destroyed  by  the  normally  protective  substances  present  in  the 
blood  circulating  through  the  highly  vascular  mucosa. 

This  physiologic  filter  is  not  able  to  resist  all  invaders,  and  considering 
the  large  volume  of  air  which  requires  disinfection  by  the  nose,  it  is  not  at 
all  strange  that  the  frequency  of  nasal  infection  is  great.  It  is  therefore 
easy  to  see  that  diseases  of  this  region  are  usually  the  first  to  affect  children. 

Small  primary  foci  of  infection  are  probably  formed  in  the  deeper  parts 

347 


348  TEXT-BOOK  OF  PEDIATRICS 

of  the  mucosa  from  which  they  spread  to  neighboring  areas,  whence  the 
entire  body  is  brought  into  participation  in  the  disease.  Since,  however, 
inspection  of  the  entire  inner  surface  of  the  nose  is  not  possible,  the  exact 
mechanism  of  such  infection  is  not  known. 

Usually  the  only  visible  result  of  the  infection  is  the  secretion  from  the 
mucous  membrane  of  an  exudate  which  contains  variable  proportions  of 
serum,  mucous,  blood  and  pus  cells.  Even  the  swelling  of  the  mucous 
membrane  is  not  always  directly  visible,  but  is  rather  inferred  from  the 
mouth  breathing.  The  general  disturbance  which  ensues  is  of  varying 
character  and  depends  upon  the  particular  etiologic  factor  concerned  in  the 
nasal  infection. 

Variola,  in  which  the  primary  focus  is  commonly  in  the  nasal  mucosa, 
may  be  considered  typical  of  the  infectious  diseases  which  find  their  port  of 
entry  in  the  nose.  About  fourteen  days  after  the  infection,  the  exanthem 
appears,  associated  with  severe  general  symptoms,  and  is  followed  by  the 
ultimate  formation  of  pustules.  These  develop  not  only  upon  the  skin  but 
also  throughout  the  respiratory  tract  and  particularly  in  the  nose. 

The  method  of  infection  in  measles,  a  matter  of  much  greater  impor- 
tance, may  be  theoretically  assumed  to  be  after  the  same  fashion.  Sup- 
posedly, a  primary  focus  always  precedes  the  development  of  the  disease. 
The  first  evident  disturbance  marks  the  second  stage,  which  is  a  catarrhal 
affection  of  the  respiratory  mucous  membrane  and  the  conjunctiva.  The 
child  coughs,  sneezes  and  has  a  viscid  secretion  from  the  eyes.  At  this 
stage  a  diagnosis  can  not  always  be  made  and  must  necessarily  await  the 
appearance  of  the  eruption  of  the  mucous  membrane  of  the  mcuth.  If 
Koplik's  spots  are  discovered,  a  diagnosis  of  the  coryza  as  a  prodromal 
symptom  of  measles  may  be  made  often  a  day  or  two  before  the  eruption 
upon  the  skin  appears,  permitting  the  physician  to  take  precautionary 
measures  at  once. 

Nasal  diphtheria  is  not  a  matter  of  secondary  symptoms  but  rather 
localization  of  the  micro-organism  in  the  nasal  mucosa,  with  a  resulting 
inflammatory  exudate,  which  in  infections  of  greater  intensity  leads  to  the 
formation  of  a  false  membrane.  The  diphtheria  bacilli  either  invade  the 
nose  first  or  migrate  to  it  from  the  tonsils.  In  the  latter  event  the  recog- 
nition is  easy  since  the  characteristic  exudate  can  be  seen  on  the  tonsils  or 
on  the  posterior  pharyngeal  wall.  In  cases  of  isolated  nasal  infection  the 
condition  is  not  easily  recognized  unless  the  membrane  is  located  low  in  the 
nares  or  is  expelled  by  sneezing. 

These  conditions  do  not  always  obtain,  and  since  latent  nasal  diph- 
theria is  common,  it  should  be  a  rule  to  examine  every  sanguine-purulent 
discharge  from  the  nose  for  diphtheria  bacilli.  Equally,  a  nasal  affection 
combined  with  hoarseness  should  arouse  a  suspicion  of  diphtheria.  If  a 
membrane,  or  if  diphtheria  bacilli  are  found,  an  injection  of  antitoxin 
should  be  given  at  once.  In  cases  in  which  a  fairly  well-formed  suspicion  of 
diphtheria  exists,  it  is  well  to  give  the  serum  without  waiting  for  a  report 
of  the  bacteriologic  examination.  A  similar  sanguino-purulent  nasal  dis- 
charge occurs  in  some  cases  of  scarlatina. 


DISEASES  OF  THE  RESPIRATORY  ORGANS  349 

The  diagnosis  in  such  an  event  must  be  made  from  the  exanthem  upon 
the  skin  and  upon  the  mucous  membrane  of  the  oral  cavity.  Isolated  dis- 
ease of  the  nose  as  a  result  of  scarlet  fever  has  not  been  demonstrated. 

The  rhinitis  of  scarlet  fever  is  of  great  importance  in  the  matter  of 
prognosis,  because  the  cases  with  severe  nasal  inflammation  are  usually 
serious,  and  because  the  local  infection  is  apt  to  extend  to  the  Eustachian 
tubes  and  the  middle  ear. 

A  characteristic,  chronic  affection  of  the  nose  is  seen  in  congenital 
syphilis.  A  congestion  of  the  nares'and  excoriation  of  the  surrounding 
tissues  suggests  a  scrofulous  form  of  tuberculosis  as  a  question  of  first 
consideration. 

In  the  new-born  a  gonococcic  infection  of  the  nasal  mucosa,  coincidently 
with  the  characteristic  conjunctival  blennorrhcea,  is  observed. 

Herewith  the  types  of  coryza  in  which  a  definite  infectious  agent  can  be 
demonstrated  are  practically  exhausted. 

Coryza  also  occurs  in  epidemic  meningitis  and  in  acute  poliomyelitis. 

Meningitis  probably  starts  as  a  primary  infection  in  the  nose,  and  this 
leads  to  a  metastatic  infection  of  the  meninges.  However,  since  the  nasal 
catarrh  has  no  definite  characteristics,  its  specific  quality  is  actually  recog- 
nized only  after  the  appearance  of  general  symptoms,  unless  the  occurrence 
of  cases  of  meningitis  in  the  family  suggests  the  examination -of  the  nasal 
secretion  of  all  its  members  for  the  organism  of  Weichselbaum.  The 
simple  microscopic  demonstration  of  an  intracellular  diplococcus  has  no 
significance  since  other  similar  bacteria  are  frequently  found  in  the  nose. 

Acute  poliomyelitis  also  commonly  begins  with  irifluenzal  symptoms 
but  in  this  disease  again,  with  our  present  knowledge,  diagnosis  is  impossible 
until  the  typical  paralysis  appears.  When  the  disease  is  present  in  the 
household,  the  coincident  occurrence  of  coryza  in  other  members  of  the 
family  may  lead  one  to  suspect  it  to  be  a  rudimentary  form  of  poliomye- 
litis (Wickman). 

The  existence  of  a  group  of  rather  obscure  influenzal  diseases  has  to  be 
recognized.  In  extensive  epidemics  in  which  coryza  ushers  in  catarrhal 
symptoms  of  the  mucous  membranes  and  severe  constitutional  disturbances 
and  in  which  the  influenza  bacillus  of  Pfeiffer  is  the  cause,  an  etiologic 
diagnosis  is  possibly  permissible.  In  the  sporadic  cases,  however,  which  are 
seen  almost  daily,  it  is  scarcely  ever  possible  to  determine  the  causative 
organism  with  any  degree  of  certainty.  Probably  a  large  group  of  micro- 
organisms, including  the  micrococcus  catarrhalis,  the  pneumococcus,  etc., 
behave  in  a  very  similar  manner.  Since  therapeutically  reliance  is  placed 
upon  symptomatic  measures,  a  differential  diagnosis  has  no  practical  value, 
and  the  severe  coryzas,  accompanied  by  fever  and  other  general  symptoms 
may  be  designated  as  la  grippe  or  influenza  without  implying  that  the 
condition  is  necessarily  caused  by  the  influenza  bacillus  itself. 

In  addition  to  these  infectious  causes  of  coryza,  there  are  other  influ- 
ences which  in  especially  predisposed  individuals  produce  acute  affections 
of  the  nasal  mucosa.  A  typical  example  is  tuberculin  coryza.  When  an 
individual  who  is  especially  sensitive  to  tuberculin  inhales  this  agent  or  the 


350  TEXT-BOOK  OF  PEDIATRICS 

tubercle  bacilli  in  pulverized  form,  he  is  subject  to  coryza  which  may  be 
considered  analogous  to  the  conjunctival  tuberculin  reaction.  Similarly, 
there  are  persons  who  react  by  an  attack  of  coryza  to  the  inhalation  of 
horse  dandruff.  An  important  clinical  picture  showing  this  tendency  in  one 
form  is  hay  fever. 

In  some  people  the  inhalation  of  air  laden  with  the  pollen  of  certain 
plants  produces  severe  irritation  of  the  respiratory  tract  and  especially  of 
the  nasal  mucous  membrane.  Those  susceptible  suffer  with  a  persistent 
swelling  and  hypersecretion  of  the  mucous  membranes  \vhen  these  plants 
are  in  bloom,  an  event  which  occurs  chiefly  in  the  early  summer  and  less 
generally  in  the  fall.  That  the  coryza  is  excited  by  the  pollen  is  proved  by 
the  fact  that  in  the  predisposed  individual  the  manifestations  of  hay  fever 
can  be  induced,  even  in  winter,  by  the  instillation  of  a  suspension  of  the 
pollen,  while  a  normal  person  does  not  react.  It  is  quite  certain  that  a  large 
proportion  of  acute  cases  of  coryza  in  the  adult  may  be  charged  to  hyper- 
sensibility  to  certain  foreign  substances.  In  early  childhood,  however,  such 
hypersensibility  probably  merits  less  consideration.  Hay  fever  hardly  ever 
appears  before  the  close  of  childhood. 

In  every  day  life,  coryza  due  to  exposure  to  cold  plays  an  important 
role.  Cold  in  itself  cannot  be  regarded  as  the  cause,  since  polar  explorers 
remain  free  from  catarrh  in  spite  of  the  most  severe  exposure.  (Nansen, 
Shackleton.)  Similarly,  in  the  open  air  department  of  the  hospital,  no 
catarrhal  affections  could  be  traced  to  exposure  to  cold,  although  the 
children  slept  out  of  doors,  at  zero  temperature.  It  must  be  presumed, 
however,  that  the  invading  organisms  more  readily  find  a  foothold  when  in 
consequence  of  the  cooling  of  the  body,  the  secretion  of  the  protective  fluids 
do  not  occur  normally. 

The  pathologic  anatomy  of  a  mild  coryza  shows  only  a  swelling  and 
congestion  of  the  nasal  septum  and  of  the  lower  turbinates.  In  severe 
cases,  the  deeper  parts  of  the  mucous  membrane  are  also  involved  in  a 
mucopurulent  inflammation.  From  here  the  process  may  spread  to  the 
Eustachian  tubes  and  the  middle  ear. 

THE  CLINICAL  SYMPTOMS  OF  ACUTE  RHINITIS 

The  first  sign  of  acute  coryza  is  usually  frequent  sneezing.  Then  in  a 
few  hours  there  is  a  rise  of  temperature,  accompanied  by  a  watery  secretion 
from  the  nasal  mucous  membrane.  During  the  next  few  days  the  secretion 
becomes  mucous  and  clouded  with  pus  cells.  Finally  it  becomes  more  and 
more  purulent  and  tenacious.  At  the  same  time,  the  swelling  of  the  mucous 
membrane  makes  nasal  breathing  difficult.  This  becomes  most  annoying, 
especially  in  infancy.  The  infant  when  nursing  from  the  breast  takes  a 
very  firm  hold  of  the  nipple  and  while  sucking  breathes  quietly  through  the 
nose.  Whenever,  then,  the  nose  is  partially  obstructed,  breathing  is 
difficult,  and  if  the  obstruction  is  complete,  the  nursing  must  be  interrupted 
repeatedly  in  order  that  the  child  may  breathe  through  the  mouth.  Then 
the  child  loses  its  patience  and  its  desire  to  nurse.  Occasionally  the 
condition  may  cause  attacks  of  choking  on  account  of  which,  in  the  early 


DISEASES  OF  THE  RESPIRATORY  ORGANS  351 

months  of  life,  coryza  may  lead  to  alarming  symptoms.  At  other  times 
the  respiratory  rate  is  greatly  increased  and  the  sleep  consequently  dis- 
turbed because  the  infant  attempts  to  breathe  through  the  mouth  and 
nose  alternately. 

As  a  result  of  the  general  infection,  fever,  and  anorexia,  the  child  be- 
comes debilitated,  loses  weight,  and  may  even  die  of  a  complicating  bron- 
chitis or  broncho-pneumonia. 

Until  the  third  or  fourth  year,  a  severe  coryza  must  be  looked  upon  as  a 
serious  disorder,  because  of  its  possible  complications,  while  in  later  child- 
hood it  is  usually  as  readily  overcome  as  it  is  in  adult  life. 

Acute  inflammation  of  the  pharyngeal  tonsil  (the  lymphoid  tissue  of  the 
nasopharynx)  does  not  necessarily  lead  to  severe  symptoms.  In  children 
with  exudative  diatheses,  such  an  inflammation  is  common  during  infancy. 
It  is  apt  to  cause  fever,  malaise,  disturbances  of  respiration  but  not  always 
a  nasal  discharge.  Very  frequently  a  reddening  of  the  posterior  pharyngeal 
wall  is  the  only  finding  that  will  explain  some  irregularities  of  temperature 
in  infancy. 

An  indication  of  acute  inflammation  of  the  nasopharynx  is  given  by  the 
enlargement  of  the  lymph  nodes  of  the  posterior  cervical  triangles,  while  a 
swelling  of  the  nodes  in  the  anterior  or  sublingual  triangles  is  indicative  of  an 
inflammatory  process  in  the  tonsils. 

The  therapy  of  acute  rhinitis  consists  essentially  in  combating  the 
general  disease.  If  there  is  a  mucopurulent  or  sanguineous  discharge,  an 
examination  for  diphtheria  bacilli  should  be  made.  If  the  suspicion  is  in 
the  slightest  degree  justified,  antitoxin  should  be  used.  The  nasal  mucous 
membrane  is  not  very  accessible  to  treatment.  The  injection  of  antiseptic 
fluids  is  contraindicated  on  account  of  the  liability  to  forcing  fluid  and 
infected  mucous  into  the  middle  ear. 

An  inert  or  mildly  antiseptic  ointment  containing  boric  acid  or  zinc 
oxide  may  be  used  to  prevent  the  excoriation  of  the  skin  by  the  secreted  pus. 
If  crusts  or  dried  discharge  are  formed  in  the  nares,  small  wooden  appli- 
cators, such  as  a  match  stick  or  toothpick,  mounted  with  cotton  and  covered 
with  ointment  may  be  placed  in  the  nostrils  for  a  few  minutes,  but  of  course 
only  while  the  child  is  under  observation.  Instead,  several  drops  of  warm 
olive  oil  or  almond  oil  may  be  instilled  carefully  into  the  nose  several  times 
a  day.  Possibly  1  per  cent,  of  menthol  may  be  added  to  these.  The  intro- 
duction of  pledgets  of  absorbent  cotton  saturated  with  1 : 3000  solution  of 
epinephrin  causes  a  temporary  reduction  of  the  swelling.  If  nursing  becomes 
very  difficult,  the  infant  must  be  fed  from  a  spoon.  If  this  cannot  be  done 
successfully,  it  may  be  necessary  to  feed  the  child  by  gavage.  The  general 
therapy,  if  fever  obtains,  consists  in  inducing  perspiration  by  means  of 
hot  packs,  warm  drinks  and  acetyl  salicylic  acid  (0.1-0.25  gm.  at  a  dose),  or 
quinine  (0.05-0.25  gm.  to  a  dose).  Very  young  children  should  be  kept  in 
bed,  older  ones  in  the  house. 

Recently,  calcium  lactate  has  been  highly  recommended  (Januschke). 
One  gram  a  day  may  be  given  to  infants,  while  older  children  may  receive 
five  grams  a  day.  This  treatment  is  continued  for  three  or  four  days. 


352  TEXT-BOOK  OF  PEDIATRICS 

Grams. 

R     Calcii  lactatis '. 5.0 

Syrupi  rubi  idaei 10.0 

Aquae  q.  s.  ad 100.0 

The  room  temperature  should  be  about  18°  C.  (65°  F.)  in  winter,  and  the 
air  should  be  kept  as  moist  as  possible.  The  odor  of  oil  of  turpentine  or  of 
oil  of  pine,  allowed  to  evaporate  near  the  bed,  is  very  pleasant. 

CHRONIC   CORYZA 

Subacute  chronic  inflammations  of  the  nasal  mucosa  are  common  in 
childhood.  They  result  either  from  acute  coryza  or  as  in  the  case  of  luetic 
or  scrofulous  snuffles,  they  develop  without  any  acute  stage,  and  with 
rather  an  insidious  onset.  In  the  chronic  form,  the  centre  of  the  local 
condition  is  to  be  found  almost  invariably  in  an  enlargement  of  the  lymph 
organs  of  the  nasopharynx.  The  mucosa  of  the  nares  also  shows  a  chronic 
swelling  and  secretes  a  purulent  or  mucous  discharge. 

A  peculiar  form  of  chronic  coryza  is  ozaena,  in  which  the  gubmucosa 
atrophies.  The  air  passage  is  not  obstructed,  and  there  is  a  small  quantity 
of  a  tenacious  discharge  forming  crusts  over  the  entire  mucous  membrane 
which  stagnates  the  secretion  beneath. 

Putrefactive  bacteria  (Perez),  undestroyed  because  of  the  lack  of 
normal  secretion,  cause  a  decomposition  of  the  tissues  accompanied  by  a 
characteristic  and  intensely  foul  odor.  The  disease  occurs  occasionally  in 
older  children,  who  in  almost  all  instances  present  signs  of  tuberculosis. 
The  therapy  of  ozaena  must  be  directed  chiefly  to  the  improvement  of  the 
general  health.  Locally  the  instillation  of  liquid  petrolatum  containing 
1  per  cent,  of  salicylic  acid,  or  the  tamponade  of  the  lower  nostrils  with 
cotton  pledgets  saturated  with  petrolatum  has  been  recommended. 

The  prognosis  of  chronic  coryza  depends  largely  upon  whether  it  is  or  is 
not  the  expression  of  a  chronic  infectious  disease.  Infants  should  be  care- 
fully examined  for  syphilis.  If  the  history  is  negative,  a  Wassermann  test 
should  be  made.  If  the  diagnosis  is  positive,  specific  treatment  should  be 
instituted.  To  cases  occurring  later  in  childhood,  the  tuberculin  test  should 
be  applied.  If  this  test  is  strongly  positive,  the  suspicion  that  the  coryza 
is  of  a  scrofulous  nature  is  justified.  The  proper  treatment  should  then  be 
instituted.  If  the  tuberculin  test  is  negative,  a  prognosis  of  rapid  recovery 
under  suitable  management  may  be  given  with  some  degree  of  certainty. 

Children  of  sufficient  age  should  be  made  to  wash  out  the  nose  several 
times  a  day  with  physiologic  salt  solution  or  with  luke-warm  water  contain- 
ing a  small  quantity  of  borax.  The  patient  may  be  given  a  small  portion  of 
boric  acid  ointment  (3  per  cent.)  with  instructions  to  apply  it  to  the  nostrils, 
one  nostril  being  closed  while  the  ointment  is  snuffed  into  the  other.  The 
ointment  melts  at  body  temperature  and  spreads  over  the  mucous  mem- 
brane softens  the  crusts,  and  stimulates  the  flow  of  secretion.  .  The  other 
nostril  is  then  similarly  treated.  After  ten  or  fifteen  minutes  the  child  must 
blow  its  nose  thoroughly. 

For  smaller  children,  instillations  of  sweet  oil,  cotton  tampons  saturated 
with  boric  acid  ointment,  or  insufflations  of  antiseptic  powders  may  be  used. 


DISEASES  OF  THE  RESPIRATORY  ORGANS  353 

The  best  remedy  for  the  last  purpose  is  sodium  biborate  with  10  per  cent, 
of  sodium  sozoiodolate  and  1  per  cent,  of  menthol.  A  marked  hyperplasia 
of  the  mucous  membrane  must  be  treated  by  painting  with  a  2  per  cent, 
solution  of  silver  nitrate. 

ADENOID  VEGETATIONS 

In  association  with  simple  or  scrofulous  chronic  rhinitis,  or  without  any 
affection  of  the  nasal  mucosa,  one  finds  in  children  very  frequently  an 
enlargement  of  the  lymphoid  tissues  of  the  posterior  pharynx.  In  children 
of  the  lymphatic  type  the  pharyngeal  tonsil,  together  \vi1h  faucial  tonsils 
and  other  glandular  organs,  is  often  subject  to  enormous  hypertrophy,  so 
that  it  fills  the  entire  space  intended  to  serve  as  a  passageway  for  air. 
On  this  account  the  child  is  forced  to  breathe  through  its  mouth  and  in 
consequence  acquires  after  a  time  a  characteristic  facial  expression.  His 
speech  acquires  a  peculiar  resonance,  because  the  sounds  that  are  normally 
spoken  through  the  nose  (M,  N)  or  those  that  require  a  complete  closure 
of  the  soft  palate  (P,  T,  K)  are  enunciated  indistinctly.  This  leads  some- 
times to  the  developing  of  various  types  of  lisping  or  stammering.  Stut- 
tering is  sometimes  caused  by  the  difficulty  in  breathing.  Children  who 
snore  for  want  of  a  free  passage  of  air  have  bad  dreams,  nightmares,  and 
pavor  nocturnus.  Nocturnal  enuresis  often  complicates  such  cases. 

Beside  the  effect  of  adenoid  vegetations  upon  the  speech  and  the 
respiration,  another  unpleasant  result  is  their  occlusion  of  the  Eustachian 
tube,  which  in  its  turn  causes  a  retention  of  secretion  and  the  development 
of  chronic  catarrh  of  the  tubes  and  the  middle  ear.  The  hearing  is  subse- 
quently affected,  and  the  child  is  retarded  in  his  school  progress. 

When  adenoid  vegetations  are  very  large,  they  have  a  further  effect 
upon  the  nasal  skeleton.  The  development  of  the  bony  structure  of  the 
nose  is  delayed,  as  a  consequence  of  which  the  eyes  protrude,  giving  an 
appearance  resembling  Basedow's  disease. 

Adenoids  may  occur  even  in  infancy,  but  they  are  most  commonly  seen 
between  the  fourth  and  the  tenth  year.  Without  treatment  they  may 
persist  for  years,  but  they  tend  to  disappear  toward  the  end  of  childhood. 
In  many  cases  enlarged  cervical  and  sublingual  lymph  nodes  occur  coin- 
cidently  and  probably  result  from  adenoid  vegetations.  They  usually 
disappear  after  the  adenoids  have  been  removed. 

The  diagnosis  is  readily  made  upon  the  evidence  of  the  mouth  breathing, 
the  nasal  speech,  and  the  history  of  snoring  and  deafness.  Many  physi- 
cians are  inclined  in  every  case  of  obstruction  of  the  nose  to  diagnose  the 
presence  of  adenoids  or  polyps.  Frequently  the  obstruction  is  due  to  a 
narrowness  of  the  nasal  passage,  which  is  acutely  exaggerated  by  intumes- 
cence of  the  turbinates.  The  diagnosis  is  confirmed  by  directly  palpating 
the  vegetations. 

For  this  purpose  the  child  is  placed  in  front  of  the  physician,  but  facing 

away  from  him.    He  is  then  told  to  open  his  mouth,  the  head  being  held 

from  behind  with  the  left  hand  pressing  the  cheeks  between  the  teeth,  so 

that  the  child  cannot  bite  without  hurting  himself.    His  hands  must  be 

23 


354  TEXT-BOOK  OF  PEDIATRICS 

held  by  an  attendant.  The  index  finger  of  the  right-  hand  is  then  rapidly 
introduced  into  the  open  mouth,  passing  back  through  the  fauces  and 
exploring  the  posterior  pharyngeal  wall. 

Therapy. — If  the  vegetations  are  very  large  and  cause  much  annoyance, 
they  should  be  removed  surgically.  Anesthesia  is  not  absolutely  necessary. 
After  the  operation,  the  patient  should  be  kept  away  from  other  children 
for  several  days  on  account  of  the  danger  of  infection  of  the  wound  surface. 
If  the  symptoms  produced  by  the  growth  are  slight,  or  if  coryza  or  an- 
gina is  present,  the  treatment  should  be  expectant.  Topical  treatment  of 
the  adenoid  has  no  effect.  The  causative  scrofulous  condition  should  re- 
ceive attention. 

FOREIGN  BODIES  IN  THE  NOSE 

Small  children  often  force  small  objects  such  as  stones,  beans,  or  seeds 
into  the  nostrils.  Occasionally  a  foreign  body  is  forced  through  the  naso- 
pharynx into  the  nose  and  becomes  lodged  in  the  anterior  nares  during 
vomiting.  Such  bodies  may  cause  local  inflammation  which  creates  a  foul- 
smelling,  bloody  discharge.  In  other  cases  these  objects  become  encrusted 
and  are  termed  rhinoliths. 

If  the  child  is  observed  in  the  act  of  forcing  the  foreign  body  into  its 
nose,  the  treatment  is  usually  simple.  If  the  body  has  become  lodged  in  the 
nostril,  it  can  often  be  pressed  out,  or  it  may  be  expelled  if  the  nose  is  blown 
while  the  other  nostril  is  held.  In  very  young  children,  the  Politzer  bag 
may  be  applied  to  the  open  side,  a  procedure,  however,  which  requires 
great  care. 

If  the  diagnosis  cannot  be  made  from  the  history,  a  foul-smelling  dis- 
charge from  one  nostril  continuing  for  a  long  period  is  a  quite  definite  indi- 
cation of  a  foreign  body.  In  acute  cases  diphtheria  must  be  borne  in  mind. 
In  these  cases  of  impaction  the  removal  of  the  object  is  not  always  easy, 
since  the  foreign  body  may  swell,  or  it  may  be  imbedded  in  the  granulation 
tissue.  Attempts  may  be  made  to  blow  the  substance  out  with  air  or  to 
wash  it  out  with  warm  water  after  reducing  the  swelling  of  the  mucosa  by 
cocainizing  it.  If  the  body  lies  deep,  it  is  sometimes  easier  to  push  it 
through  the  posterior  nares  to  the  throat.  Sometimes  it  is  possible  to  pull 
the  foreign  body  out  with  a  fine  forceps  or  with  a  hooked  probe. 

Similar  symptoms  may  be  produced  by  polypi,  which  are  very  rare  in 
childhood.  They  must  be  removed  surgically. 

EPISTAXIS 

Nose-bleed  in  children,  not  occurring  as  a  symptom  of  hemophilia, 
hemorrhagic  diathesis,  leucemia,  pertussis,  typhoid  fever,  or  a  heart  lesion, 
is  usually  due  to  injury  or  is  the  result  of  picking  the  nose.  The  hemor- 
rhage comes  from  the  anterior  portion  of  the  septum.  It  is  readily  stopped 
when  it  is  not  a  symptom  of  one  of  the  above  named  diseases.  The  child  is 
made  to  snuff  up  cold  water  from  the  hand.  If  this  does  not  succeed,  the 
lower  nose  may  be  tamponed  with  a  strip  of  gauze.  This  gauze  may  be 
saturated  with  hydrogen  peroxide.  This  medication  frequently  produces  a 


DISEASES  OF  THE  RESPIRATORY  ORGANS  355 

rapid  cessation  of  the  noee-bleed.  After  the  bleeding  has  stopped,  deter- 
mine whether  a  chronic  inflammation  of  the  nostrils  has  caused  irritation 
and  invited  injury.  If  this  is  the  case,  a  1  per  cent,  ointment  of  ammoniated 
mercury  may  be  applied  to  the  nostrils,  or  the  hemorrhagic  area  on  the 
septum  may  be  touched  with  a  2  to  5  per  cent,  solution  of  silver  nitrate. 

In  early  infancy  epistaxis  suggests  some  serious  condition  and  should 
raise  the  question  of  sepsis,  scurvy,  diphtheria  or  syphilis. 

DISEASES  OF  THE  EUSTACHIAN  TUBES  AND  THE  MIDDLE 

EAR 

One  of  the  most  frequent  complications  of  the  diseases  of  the  respiratory- 
organs  in  childhood  is  the  extension  of  the  inflammatory  process  to  the 
mucous  membrane  of  the  middle  ear.  Its  frequency  is  due  in  part  to  the 
structural  peculiarities  of  the  child's  auditory  apparatus,  and  for  the 
remainder,  to  the  general  predisposition  to  infection  of  the  mucous  mem- 
branes of  the  young.  In  the  new-born  the  organ  of  hearing  is  not,  like  that 
of  sight,  completely  formed,  but  undergoes  its  final  development  in* post- 
natal life. 

The  chief  cause  for  the  extension  of  the  inflammation  from  the  pharynx 
is  that  the  cartilaginous  portion  of  the  Eustachian  tube  is  much  shorter 
than  in  later  life,  while  at  the  s?me,  time  its  lumen  is  decidedly  greater. 
The  pharyngeal  opening  of  the  tube  is  very  much  lower.  In  the  new-born  it 
lies  at  about  the  level  of  the  hard  palate  and  in  the  adult  about  one  centi- 
metre higher.  The  papillary  fold  covering  the  Opening  is  formed  toward 
the  end  of  the  first  year.  At  birth  the  depression  is  small  and  lies  directly 
above  and  behind  the  opening  into  the  ear.  In  the  fetus  the  tympanum  is 
filled  with  a  pad  of  dense  embryonal  connective  tissue,  which  usually  dis- 
appears before  birth. 

The  tympanic  membrane  in  the  new-born  forms  a  part  of  the  external 
surface  of  the  cranium.  It  is  obliquely  placed  and  directed  downward, 
whereas  in  later  life  it  is  almost  vertical.  The  membrane  itself  is  usually 
thicker  and  more  opaque  than  in  older  children,  but  it  soon  acquires  its 
distinctive  delicacy  and  transparency. 

The  external  auditory  canal  is  short  and  consists  of  a  soft  cleft-like 
channel  without  bony  structure  and  cartilaginous  only  at  its  outerextremity. 

An  examination  of  the  tympanic  membrane  of  the  new-born  must  be 
done  with  a  speculum.  A  very  short  and  thin-walled  one  is  necessary  on 
account  of  the  shortness  of  the  canal.  The  examination  must  be  carried 
out  cautiously.  Difficulty  lies  in  the  fact  that  the  membrane  is  very 
obliquely  placed.  Again,  the  canal  is  usually  filled  with  vernix  caseosa. 
To  remove  this,  the  canal  may  be  washed  out  with  tepid  water  to  which 
hydrogen  peroxide  has  been  added.  For  this  purpose  a  fine  soft  tube  is 
fastened  to  the  tip  of  a  syringe.  The  most  important  point  of  orientation  is 
the  short  handle  of  the  malleus.  The  normal  membrane  of  the  new-born  is 
gray,  but  when  the  child  cries,  it  becomes  pink,  a  change  which  must  not 
be  mistaken  for  evidence  of  inflammation.  After  the  third  month,  inspec- 
tion is  an  easier  matter  and  in  still  later  childhood,  the  picture  resembles 


356  TEXT-BOOK  OF  PEDIATRICS 

that  of  the  adult  more  and  more.  An  attempt  should  always  be  made  first 
to  inspect  the  drum  without  the  speculum.  The  child  will  remain  quieter 
when  he  is  not  frightened  by  the  insertion  of  the  instrument,  and  since 
hairs  are  absent  from  the  meatus,  the  membrane  can  usually  be  seen  quite 
well  in  part  if  not  as  a  whole.  In  order  to  make  the  inspection  without  the 
speculum,  it  is  necessary  to  stretch  the  canal  by  lifting  the  external  ear 
upward  and  outward  with  the  second  and  third  fingers,  while  the  tragus 
is  pushed  forward  with  the  thumb.  If  the  handle  of  the  malleus  is  seen,  the 
gray  color  of  the  membrane  distinguished,  and  the  normal  reflex  appears, 
the  examination  is  completed.  Only  when  a  pathologic  condition  exists 
is  the  speculum  employed  in  order  to  get  a  more  accurate  diagnosis.  If  it 
is  not  merely  a  question  of  finding  out  whether  there  is  a  discharge,  it  is  not 
necessary  to  use  a  speculum  but  instead  to  introduce  peroxide  of  hydrogen. 
The  child  is  laid  on  the  other  ear,  and  three  or  four  drops  of  3  per  cent, 
hydrogen  peroxide  solution  are  dropped  in  the  external  ear  while  the  audi- 
tory canal  is  kept  closed.  After  the  solution  has  had  time  to  get  warm,  it  is 
permitted  to  flow  slowly  into  the  meatus.  The  formation  of  a  large  amount 
of  foam  indicates  the  presence  of  pus  in  the  canal;  a  slight  foaming  may 
come  from  a  minute  amount  of  pus  or  from  cerumen  present. 

OTITIS  MEDIA  CATARRHALIS  NEONATORUM 

At  autopsies  of  the  new-born  or  of  very  young  infants,  more  or  less 
purulent  matter  is  found  in  the  tympanum  in  a  surprisingly  large  number 
of  cases  (40-90  per  cent.).'  Children  who  die  before  or  during  birth  always 
have  amniotic  fluid  or  meconium  in  the  middle  ear,  which  is  probably 
pumped  into  the  ears  by  premature  efforts  at  respiration.  If  they  live  for  a 
short  time,  a  collection  of  leucocytes  without  bacterial  contamination  is 
formed,  which  may  be  considered  in  the  nature  of  a  pus  formation  around 
a  foreign  body  (Aschoff).  A  similar  affection  seems  to  occur  very  fre- 
quently in  the  healthy  new-born.  Gompers  found  by  a  systematic  exami- 
nation of  infants  at  birth  that  in  nearly  fifty  per  cent,  of  them  a  swelling  or 
bulging  or  at  least  a  reddening  of  the  tympanic  membrane  appeared,  which 
continued  untilthe  sixth  tothe  eighth  day  and  then  subsided  to  anormal  state. 

The  exudate  disappears  either  by  resorption,  or  it  flows  off  through 
the  tube.  It  never  causes  rupture  of  the  membrane.  No  clinical  manifes- 
tations have  been  demonstrated.  Therapeutic  and  prophylactic  measures 
are  superfluous. 

ACUTE  OTITIS  MEDIA 

The  middle  ear  may  be  invaded  by  the  most  varied  infections.  The 
micro-organisms  probably  reach  it,  as  already  suggested,  in  the  majority 
of  instances  by  way  of  the  Eustachian  tube.  This  is  true  of  the  otitis  of 
scarlet  fever,  of  diphtheria,  and  of  the  various  influenzal  diseases.  In  mea- 
sles, the  infection  may  be  spread  through  the  blood  channels,  appearing 
as  an  exanthem  of  the  middle  ear.  This  route  of  infection  is  surely  true 
of  certain  of  the  tuberculous  lesions. 

In  small  children,  the  transmission  of  infection  seems  to  be  favored  by 


DISEASES  OF  THE  RESPIRATORY  ORGANS  357 

repeated  vomiting,  as  well  as  by  the  large  calibre  and  shortness  of  the 
Eustachian  tube  (Goeppert).  Etiologically,  the  pneumococcus  is  the  or- 
ganism most  commonly  found  in  the  exudate  of  otitis  media.  According 
to  Prey  sing,  it  is  responsible  for  92  per  cent,  of  all  cases.  The  strepto- 
coccus comes  next  in  frequency  and  various  other  bacteria  follow.  It 
cannot  be  said  that  the  bacteriologic  findings  suggest  any  distinctive  course 
or  any  differential  prognosis,  although  in  general  the  pneumococcus  seems 
to  be  more  benign  than  the  streptococcic  infection. 

The  symptoms  of  acute  otitis  vary  greatly.  It  may  be  said  that  the 
younger  the  child,  the  more  frequently  is  otitis  overlooked,  because  in 
small  children  it  causes  no  symptoms  at  all  or  but  very  indistinct  ones.  In 
some  cases  there  is  no  pain  at  all.  With  the  occurrence  of  general  restless- 
ness, lassitude,  sensitiveness,  anorexia,  and  fever,  without  any  other  focal 
symptoms,  disease  of  the  middle  ear  must  always  be  considered. 

If  the  child  rubs  his  head  on  the  pillow  and  is  unable  to  find  a  comfort- 
able position  in  which  to  go  to  sleep,  and  particularly  if  he  puts  his  hand 
repeatedly  to  the  head,  it  may  be  inferred  that  the  ear  is  painful. 

Pressure  over  the  tragus  usually  reveals  distinct  tenderness.  The  in- 
fant prefers  to  lie  on  the  affected  ear  if  the  condition  is  unilateral,  and  often 
prefers  to  nurse  from  the  opposite  breast  (Pins).  If  the  pain  is  severe, 
the  child 's  appetite  completely  disappears,  and  he  shows  a  tendency  to 
vomit  and  will  cry  for  hours.  Convulsions,  coma  and  meningeal  symptoms 
may  arise.  Continual  movements  of  mastication  have  been  observed. 

Other  children  may  localize  the  pain  very  definitely,  but  even  with 
them  otitis  may  be  entirely  painless,  and  its  existence  may  be  discovered 
only  after  the  rupture  of  the  membrane.  The  rupture  is  caused  by  the 
pressure  of  the  exudate  and  probably  occurs  more  easily  and  less  painfully 
with  the  thin  delicate  membrane;  so  that  the  younger  the  child,  the  less 
the  discomfort. 

The  temperature  varies  within  wide  limits.  It  may  run  over  40° 
C.  (104°  F.)  for  several  days,  and  again  its  rise  may  be  hardly  noticeable. 
The  regional  lymph  nodes  do  not  become  enlarged  in  all  cases.  Those 
situated  behind  the  ear,  back  of  the  sternomastoid  muscle,  and  in  sub- 
acute  processes  those  in  front  of  the  tragus  are  affected. 

The  duration  of  an  acute  attack  of  otitis  is  rather  variable.  It  may 
reach  its  maximum  within  twenty-four  hours,  while  in  other  cases  it  may  go 
on  for  several  days  before  rupture  takes  place.  When  the  rupture  occurs, 
the  pain  usually  disappears.  The  discharge  is  at  first  sanguino-serous,  and 
later  becomes  mucopurulent,  then  purulent,  and  finally  mucoid.  It  may 
produce  an  eczema  of  the  external  auditory  canal  and  of  the  auricle.  The 
discharge  continues  for  a  variable  period.  It  may  disappear  after  a  few 
days,  or  it  may  become  a  chronic  otitis.  Perforation,  however,  is  not  the 
only  method  of  termination  of  an  acute  otitis.  In  the  majority  of  cases 
thereisnoruptureofthemembrane,butspontaneousresorptionoftheexudate. 

The  diagnosis  of  acute  otitis  is  based  upon  the  local  tenderness  and  the 
discharge  from  the  ear.  When  rupture  has  not  taken  place,  the  diagnosis 
depends  entirely  upon  the  examination  of  the  ear-drum.  If  the  middle 


358  TEXT-BOOK  OF  PEDIATRICS 

ear  is  filled  \vith  a  catarrhal  secretion,  the  membrane,  if  thin,  shows  a 
change  from  its  normal  pearl  gray  tint  to  a  yellowish-brown  color.  It  is 
possible,  if  the  cavity  is  not  completely  filled,  to  distinguish  a  dividing  line 
between  the  fluid  and  the  air.  As  soon  as  the  membrane  itself  becomes 
inflamed,  it  takes  on  a  bright  color,  appearing  first  around  the  handle  of  the 
malleus  and  later  becoming  distinct  around  the  periphery  of  the  membrane. 
This  reddening  may  be  very  intense  and  is  sometimes  accompanied  by  small 
ecchymoses.  The  landmarks  disappear.  In  very  weakly  children  and 
especially  in  atrophic  infants,  the  redness  may  be  lacking,  and  then  the 
diagnosis  must  depend  upon  the  dulness  and  bulging. 

Perforation  generally  takes  place  in  the  lower  posterior  quadrant  and 
because  of  its  small  size  is  not  easily  recognized.  In  acute  otitis  the  rupture 
hardly  ever  becomes  larger  than  about  one  millimeter  in  diameter.  It  may 
be  possible  at  times  to  see  a  small  droplet  of  pus  forming  over  the  opening. 
The  upper  half  of  the  tympanic  membrane  may  also  rupture,  an  event 
especially  common  in  infancy. 

The  prognosis  of  acute  otitis  depends  in  some  degree  upon  the  nature  of 
the  disease  process  and  again  upon  the  general  condition  of  the  child.  The 
otitis  of  scarlet  fever  is  particularly  to  be  dreaded  because  it  may  lead  to  the 
destruction  of  the  auditory  ossicles  and  the  infection  of  the  internal  ear  and 
of  the  mastoid.  This  tendency  is  seen,  however,  only  in  certain  epidemics. 
Generally  speaking,  the  otitis  of  scarlet  fever  cannot  be  distinguished  from 
other  forms. 

In  diphtheria  a  perforating  otitis  is  rare,  but  autopsies  show  that  a 
diphtheritic  membrane  may  extend  to  the  Eustachian  tubes  and  to  the 
middle  ear.  This  type  of  infection  does  not  cause  serious  destruction. 
Measles,  during  the  catarrhal  stage,  sometimes  leads  to  an  otitis  of  a  tem- 
porary character.  The  middle  ear  inflammation,  however,  which  constitutes 
one  of  the  secondary  infections  resulting  from  measles,  must  be  considered 
a  much  more  serious  matter.  This  type  has  a  tendency  to  become  chronic. 

Inflammation  of  the  middle  ear  is  most  frequent  as  a  complication  of 
influenza  and  la  grippe.  This  form  lasts  usually  from  four  to  eight  days, 
and  even  though  perforation  occurs,  recovery  takes  place  within  eight  OP 
ten  days.  The  rupture  of  the  drum  commonly  heals  very  rapidly  and 
generally  without  a  scar.  The  hearing  is  not  particularly  affected  by  sup- 
puration of  short  duration. 

An  exception  to  this  rule  is  to  be  noted  in  weak  and  especially  scrofulous 
children.  In  these  cases  perforations  show  no  tendency  to  heal,  and  the 
result  is  frequently  a  chronic  otitis. 

From  the  standpoint  of  prognosis,  the  occurrence  of  complications  is  of 
the  utmost  importance.  The  commonest  are  mastoiditis,  subperiosteal 
abscesses,  necroses  of  the  temporal  bone,  and  the  extension  of  the  inflamma- 
tion to  the  meninges.  Prompt attentionshouldbedirectedtoanyinflamma- 
tory  swelling  or  tenderness  behind  the  ear.  If  these  do  not  subside  within 
two  or  three  days,  surgical  procedures  must  be  instituted.  A  sign  of  inflam- 
matory invasion  of  the  parts  surrounding  the  middle  ear  is  the  rat  her  frequent 
paresis  of  the  facial  nerve.  It  usually  disappears  after  the  suppuration  has 


DISEASES  OF  THE  RESPIRATORY  ORGANS  359 

subsided.  Intensive  meningeal  symptoms  are  always  cause  for  alarm. 
Simple  vomiting  is  not  necessarily  an  important  symptom. 

There  is  no  rational  prophylaxis  against  otitis.  In  young  children  the 
danger  of  the  infection  of  the  middle  ear  from  within  is  present  in  every 
attack  of  coryza. 

The  therapy  consists  in  promoting  the  action  of  the  skin  and  of  the 
intestinal  tract  with  a  view  to  modifying  the  general  symptoms.  A  warm 
pack,  a  sweat-bath,  hot  drinks  and  sodium  salicylate  may  be  given.  If  the 
child  has  not  had  a  free  movement  of  the  bowels,  active  catharsis  some- 
times has  an  abortive  influence  upon  middle  ear  disease.  If  the  patient 
suffers  very  severe  pain  and  sleeplessness,  small  doses  of  phenacetin  (0.05- 
0.2  gm.)  or  of  veronal  in  doses  of  0.02-0.2  gnu  may  be  given  in  milk.  Occa- 
sionally quinine  gives  good  results. 

If  the  tympanic  membrane  is  distinctly  reddened  and  bulging,  para- 
centesis  should  be  performed.  The  puncture  is  made  with  a  long  knife  in  the 
lower  posterior  quadrant.  It  is  not  necessary  to  anesthetize  the  membrane 
although  a  piece  of  gauze  saturated  in  a  10  per  cent,  solution  of  cocaine  may 
be  applied.  If  the  paracentesis  is  done  at  the  proper  time,  a  bloody  or 
purulent  discharge  should  immediately  appear.  The  cut  should  be  from 
two  to  three  millimeters  long.  After  the  puncture  has  been  made,  a  strip  of 
iodoform  or  sterile  gauze  may  be  placed  loosely  in  the  canal  and  the  dressing 
held  in  place  by  a  hood,  which  will  make  it  easy  to  change  the  gauze. 

Paracentesis  should  be  done  only  when  there  is  a  definite  bulging  and 
severe  pain,  but  not  in  those  numerous  cases  in  which  there  is  an  abnormality 
of  the  membrane  without  clinical  symptoms,  or  pain  without  definite  drum 
abnormalities.  Pediatricians,  indeed,  have  almost  entirely  abandoned  this 
practice  in  infants,  since  results  are  no  better  with  the  operation  than 
without  it.  Even  though  spontaneous  rupture  occurs,  the  time  required  for 
healing  is  no  longer  than  that  required  after  operation,  and  in  many  cases 
the  membrane  never  ruptures. 

It  is  best,  therefore,  to  attempt  to  control  the  pain  with  hot  applica- 
tions. At  the  same  time,  warm  oil  with  1  per  cent,  of  menthol,  or  glycerin 
with  5  per  cent,  of  phenol  may  be  run  into  the  ear,  or  pledgets  of  cotton  sat- 
urated with  one  or  the  other  of  these  agents  may  be  inserted  into  the  canal. 

If  perforation  has  occurred,  the  ear  should  be  cleaned  frequently  by 
irrigation  with  hot  sterile  water,  after  which  it  must  be  carefully  dried  with 
pledgets  of  cotton.  Insufflation  of  an  antiseptic  powder  such  as  boric  acid 
may  be  tried.  If  the  canal  is  irritated  by  the  discharge,  a  1  per  cent,  am- 
moniated  mercuric  ointment  may  be  applied.  • 

CHRONIC  OTITIS  MEDIA 

A  number  of  cases  beginning  as  acute  otitis  do  not  recover,  but  continue 
to  suppurate  for  months  and  even  years.  The  cause  of  the  chronicity  lies 
either  in  the  etiology  of  the  primary  inflammation  or  in  the  general  poor 
condition  which  prevents  a  tendency  to  healing.  For  this  reason  chronic 
otitis  is  very  frequently  seen  in  children  who  have  signs  of  tuberculosis 
or  syphilis. 


360  TEXT-BOOK  OF  PEDIATRICS 

The  therapy  of  chronic  otitis  consists  first  in  the  treatment  of  the  basic 
condition.  If  the  discharge  is  tenacious  and  foul-smelling,  the  ear  may  be 
irrigated  with  a  1  per  cent,  solution  of  hydrogen  peroxide,  or  with  boric 
acid  solution,  or  with  a  weak  solution  of  potassium  permanganate.  The 
simultaneous  affections  of  the  nose  and  nasopharynx  (adenoids)  should  re- 
ceive attention.  Careful  examination  should  be  made  to  see  whether  the 
discharge  is  kept  up  by  the  presence  of  polypi,  granulations,  or  chronic 
disease  of  the  mastoid. 

FOREIGN  BODIES  IN  THE  EXTERNAL  AUDITORY  CANAL 

Unilateral  earache,  without  coryza,  arouses  suspicion  of  a  foreign  body, 
which  in  children  is  frequently  found  in  the  auditory  canal.  Fruit  seeds, 
flies,  etc.,  becoming  impacted  in  the  cerumen,  form  a  hard  mass.  It  is 
better  to  soften  this  mass  slowly  by  repeated  irrigation  with  lukewarm  water 
than  to  try  immediate  instrumental  extraction. 

CONGENITAL  STRIDOR 

Audible  respiration  occurs  in  children  from  various  causes.  In  obstruc- 
tion of  the  nasal  passages  (coryza)  or  of  the  nasopharynx  (adenoids),  the 
respiration  becomes  snuffling,  usually  associated  with  mouth-breathing  and 
snoring  while  asleep.  Swelling  in  the  tonsillar  region  (angina,  diphtheria, 
scarlatina,  tonsilitis,  retropharyngeal  abscess  and  chronic  hyperplasia  of 
the  tonsils), causes  a  snoring  respiration  while  awake,  associated  with  diffi- 
culty in  swallowing.  Noisy  respiration  is  also  caused  by  pathology  far- 
ther down  in  the  respiratory  tract.  A  mainly  expiratory,  rattling  sound  is 
heard  in  bronchitis.  Bronchial  asthma  and  intumescent  bronchial  gland 
tuberculosis  cause  expiratory  wheezing.  Mainly  inspiratory  is  the  stri- 
dor  in  enlargement  of  the  thymus,  the  thyroid,  and  in  mediastinal  ab- 
scess (Rach).  The  expiratory  grunt  of  pneumonia,  the  in-  and  expiratory 
stridor  with  hoarseness  in  diphtheria  and  pseudocroup,  and  without  hoarse- 
ness in  edema  of  the  larynx,  foreign  bodies  and  stenosis,  originate  within  the 
larynx  itself. 

An  inspiratory  crow  with  free  expiration  occurs  in  pertussis,  laryngo- 
spasm,  and  is  a  congenital  affair.  In  pertussis  the  crowing  occurs  only  dur- 
ing the  coughing  attack.  Laryngismus  stridulus,  like  the  other  symptoms 
of  tetany  and  rickets,  never  occurs  before  the  third  month  of  life,  and  then 
only  in  attacks  and  never  during  sleep.  When  the  history  reveals  that  the 
inspiratory  difficulty  has  been  present  since  birth  and  persists  during  sleep, 
the  case  is  one  of  congenital  stridor.  These  children  have  a  mediocre  or 
weak  constitution  with  negative  findings  in  the  lungs  and  other  organs. 
Retraction  of  the  suprasternal  notch  and  epigastrium  are  seen  only  excep- 
tionally if  the  inspiration  is  especially  labored.  This  noise  is  caused  either 
by  a  congenital  anomaly  of  the  larynx,  i.  e.,  a  narrowing  of  the  entrance  of 
the  larynx  due  to  a  narrowing  of  the  epiglottis  and  too  close  approxima- 
tion of  the  aryepiglottic  folds,  or  by  an  insufficient  tissue  turgor  of  the 
larynx  (Heubner). 

The  prognosis  of  this  disease  is  generally  good,  although  occasionally 


DISEASES  OF  THE  RESPIRATORY  ORGANS  361 

deaths  from  suffocation  have  occurred.    With  the  growth  of  the  larynx,  the 
noise  usually  disappears  in  the  first  or  at  the  latest  the  second  year  of  life. 
No  therapy  is  known.    Occasionally  placing  the  child  on  the  side,  or 
stomach,  causes  a  slight  lessening  of  the  stridor. 


The  larynx  of  children  with  congenital  stridor  represents  in  a  way  an 
exaggeration  of  the  normal  infantile  type  of  larynx  in  which  the  entrance 
is  relatively  small.  The  narrower  the  entrance,  the  more  easily  can  a  serious 
stenosis  result  from  a  swelling  of  the  mucous  membrane.  For  that  reason, 
there  are  very  often  evidences  of  suffocation  in  young  children  with  diph- 
theria (true  croup),  but  even  in  a  common  swelling  from  a  simple  catarrh, 
little  children  can  get  attacks  of  suffocation.  In  the  non-diphtheritic  laryn- 
gitis, a  mild  and  a  serious,  or  a  superficial  and  a  deep-seated  form  can  be 
differentiated.  The  mild  form  or  simple  catarrh  consists  of  a  reddening  and 
secretion  of  the  entire  mucous  membrane  of  the  larynx  and  leads  to  hoarse- 
ness, barking  cough,  and  a  slight  fever.  The  causes  are  the  same  as  in  acute 
coryza,  but  hoarseness  can  also  come  from  breathing  overheated  or 
dusty  air,  as  well  as  from  overtaxing  the  larynx  by  continuous  crying.  The 
illness  usually  lasts  only  a  few  days.  It  is  in  itself  benign.  The  danger 
consists  only  in  a  possibility  of  an  increase  in  the  swelling  of  the  mucous 
membrane,  in  a  transition  to  the  second  stage  of  laryngitis,  and  in  a  second- 
ary complication  of  the  lungs.  Treatment  is  unnecessary  when  there  is 
no  fever.  Keep  the  child  indoors  during  cold  weather,  and  possibly  order 
inhalations.  With  fever,  as  in  acute  coryza,  give  hot  tea  with  small  doses 
of  salicylates  or  quinine,  water  or  oil  compress  on  the  chest,  as  well  as 
turpentine  inhalations. 

The  severe  form  of  superficial  laryngitis  is  known  as  pseudocroup. 
Anatomically  it  is  characterized  by  an  intensive  swelling  of  the  larynx  in 
addition  to  redness  and  secretion,  and  this  leads  to  severe  symptoms  of 
stenosis  without  formation  of  a  membrane. 

The  swelling  attacks  principally  the  mucous  folds  which  lie  at  the  lower 
surface  of  the  vocal  cords.  It  occurs  especially  when  the  child  has  been 
changed  from  a  vertical  to  a  horizontal  position,  beginning  a  few  hours 
before  going  to  bed.  On  laryngoscopic  examination  thick,  parallel,  decid- 
edly red  swellings  can  be  seen  between  the  vocal  cords. 

The  etiology  of  pseudocroup  is,  generally  speaking,  the  same  as  that  of 
acute  coryza,  with  a  special  predisposition  for  the  larynx.  .Just  as  some 
adults  have  with  every  coryza  a  completely  obstructed  nose  from  the  swell- 
ing of  the  turbinates,  while  others  suffer  from  increased  secretion,  so  many 
children  are  inclined  to  a  swelling  of  the  mucous  membrane  of  the  larynx, 
while  others  from  the  same  cause  have  a  simple  hoarseness.  Especially  sus- 
ceptible are  the  children  with  "adenoids"  and  strong  fat  children  with  exu- 
dative diathesis,  who  are  inclined  to  superficial  catarrh. 

The  attack  of  pseudocroup  runs  as  follows;  the  child  has  been  somewhat 
indisposed  for  one  or  two  days,  with  running  nose,  loss  of  appetite,  some 
coughing  and  fever,  but  so  like  a  common  cold  that  the,  parents  do  not 


362  TEXT-BOOK  OF  PEDIATRICS 

think  of  calling  for  medical  advice.  In  the  middle  of  the  night,  the  child 
awakens  with  all  the  signs  of  suffocating.  The  expiration  is  labored,  the 
cough  spasmodic  and  barking,  the  voice  hoarse  but  not  toneless,  and  inspi- 
ration is  extremely  difficult.  There  are  marked  retractions  of  the  supra- 
clavicular  regions.  When  the  first  anxiety  is  over,  the  child  breathes 
somewhat  easier,  and  after  several  hours  the  whole  acute  attack  may  be 
over,  while  the  hoarseness  remains  for  several  days.  On  the  other  hand,  the 
symptoms  may  increase  in  severity  and  in  rare  instances  lead  to  suffocation. 

For  the  diagnosis  and  therapy  it  is  of  utmost  importance  in  every  case 
of  severe  dyspnoea,  to  make  certain  at  once  whether  or  not  it  is  diphtheria. 
The  examination  with  the  laryngoscope  is  very  difficult  in  small  children, 
and  is  not  completely  diagnostic,  because  the  diphtheritic  membrane  is  not 
always  plainly  visible.  Most  of  the  time  one  must  be  satisfied  with  an 
inspection  of  the  throat.  Every  membrane  on  the"tonsils  or  pharyngeal 
wall  points  to  a  diphtheritic  affection  of  the  larynx.  Even  in  an  apparently 
simple  angina  or  bloody  discharge  from  the  nose,  laryngeal  obstruction 
should  be  regarded  as  diphtheritic,  and  without  consideration  for  the 
bacteriological  findings,  antitoxin  should  be  given.  The  giving  of  antitoxin 
can  be  disregarded  only  when  there  is  no  suspicion  of  diphtheria. 

A  sudden  appearance  of  the  stenosis,  especially  in  the  night,  with 
barking  cough,  speaks  for  pseudocroup;  diphtheria  has  an  insidious  onset. 
In  pseudocroup  there  is  seldom  a  complete  loss  of  voice,  and  in  spite  of  the 
hoarseness,  loud  tones  can  be  made.  Complete  loss  of  voice  speaks,  there- 
fore for  diphtheria.  It  is  important  to  know  that  the  initial  catarrh  of 
measles  can  cause  pseudocroup.  The  symptoms  disappear  with  the 
appearance  of  the  eruption  which  is  followed  by  a  reduction  in  the  swelling 
of  the  mucous  membrane,  and  therefore  has  a  good  prognosis.  It  is  a  dif- 
ferent matter  if  the  hoarseness  and  difficulty  in  breathing  begin  after  the 
appearance  of  the  eruption;  then  it  is  often  a  secondary  diphtheritic 
infection  and  is  associated  with  great  danger. 

The  therapy  of  pseudocroup  is  to  promote  abundant  diaphoresis; 
warm  tea,  lemonade,  mineral  water  with  milk  are  given  internally;  packs 
with  warm  water  or  warm  oil  are  used  externally.  Older  children  can 
advantageously  use  steam  inhalations.  (Bronchitis  kettle  see  Fig.  103.) 
Small  children  usually  turn  their  heads  away  from  the  steam  and  the  bed 
must  be  transformed  into  a  tent  by  covering  it  with  sheets  and  the  steam 
introduced  from  the  foot  or  side.  Care  should  be  taken  that  the  infant  does 
not  come  too  near  the  steam  pipe.  Burns  occur  frequently  from  lack  of  care. 
The  old  physicians  used  emetics  in  large  doses  (antimony  tartrate,  0.05  gm. 
with  pulvus  ipecacuanhas  1.0  gr.).  In  spite  of  numerous  recommendations, 
this  drastic  cure  has  not  been  widely  favored. 

Gratifying  results  have  been  obtained  from  hot  tea  or  lemonade  with 
salicylates  (sodium  salicylate,  acetosalicylic  acid,  etc.),  in  small  doses;  or 
with  liquor  ammonii  anisati  1.0  in  water  100.0  with  10.0  syrup,  one  tea- 
spoonful  every  two  hours,  possibly  with  the  addition  of  codein  phosphate 
0.02  gms. 

In  severe  dyspnoea,  intubation  is  indicated.     For    pseudocroup  it  is 


DISEASES  OF  THE  RESPIRATORY  ORGANS  363 

much  to  be  preferred  to  tracheotomy.  A  tracheotomy  which  takes  at 
least  fourteen  days  to  heal,  leaves  a  permanent  scar,  and  many  times  a  last- 
ing injury  to  the  voice,  is  entirely  disproportionate  to  the  illness  which  is 
over  in  a  few  hours.  Intubation  is  very  easy  in  these  cases  as  there  is  no 
membrane,  and  it  has  no  harmful  results.  After  twenty-four  hours,  the 
tube  should  be  removed  if  it  has  not  already  been  coughed  out.  It  is  very 
seldom  necessary  to  perform  an  intubation  a  second  time.  For  the  further 
treatment,  the  directions  given  in  the  chapter  on  Diphtheria  can  be  applied. 

Laryngitis  Phlegmonosa. — This  deep-seated  form  of  laryngitis  is  a  high 
grade  inflammatory  infiltration  of  the  larynx  and  the  upper  part  of  the 
trachea  and  extends  to  the  perichondrium,  becoming  very  painful. 

Laryngitis  phlegmonosa  follows  measles  or  scarlet  fever.  Without 
these,  it  is  probably  due  to  the  same  infectious  agents  as  the  ordinary 
coryza  and  bronchitis,  but  is  very  rare,  and  probably  occurs  only  in  children 
of  2-3  years,  following  pneumonia. 

Laryngitis  phlegmonosa  begins  with  a  cough,  hoarseness,  and  fever. 
These  symptoms  increase  after  several  days,  and  in  addition  an  inspiratory 
and  expiratory  stridor  occurs,  which  does  not  lead  to  acute  severe  symptoms 
of  suffocation,  but  lasts  for  days  or  weeks.  With  the  laryngoscope  the  epi- 
glottis appears  red  and  thickened,  also  the  ligamenta  aryepiglottica.  Dif- 
ferential diagnosis  from  diphtheria  is  made  by  the  absence  of  diphtheria 
bacilli;  from  pseudocroup  by  the  slow  onset  and  the  long  duration  of  the 
condition;  and  from  both,  by  the  great  tenderness  of  the  larynx  and  trachea, 
which  is  found  in  the  deep-seated  form. 

The  treatment  consists,  in  addition  to  the  general  measures  as  in  pseudo- 
croup  and  possible  intubation  or  tracheotomy,  in  local  blood  letting  at  the 
larynx.  Heubner  recommends  that  two  to  four  leeches  be  laid  in  the  vicinity 
of  the  larynx  and  that  the  patient  be  allowed  to  bleed  thoroughly. 

FOREIGN  BODIES  IN  THE  BRONCHIAL  TUBES 

The  aspiration  of  beans,  seeds,  coins,  buttons,  etc.,  occurs  not  infre- 
quently in  children.  With  larger  objects  it  is  easy  to  determine,  on  account 
of  the  acute  onset,  that  the  dyspnoea  is  due  to  aspiration  of  a  foreign  body. 
With  smaller  objects,  the  history  is  sometimes  lacking.  The  diagnosis  of  a 
foreign  body  lying  free  in  the  trachea  or  in  one  of  the  large  bronchi  may  be 
made  by  the  flapping  sound  in  respiration.  If  it  obstructs  a  bronchial 
branch,  there  is  early  an  absence  of  the  respiratory  murmur  over  one  lung 
or  a  part  of  one  lung  with  normal  percussion  findings;  later  there  is  usually 
infiltration.  With  metallic  foreign  bodies  an  X-ray  plate  is  useful  in  de- 
termining the  position.  It  is  best  to  use  the  laryngo-  or  bronchoscope 
(Kiljian) ;  with  the  latter  it  is  usually  possible  to  remove  the  foreign  body. 
If  these  methods  can  not  be  employed,  and  it  is  suspected  that  the  foreign 
body  is  in  the  upper  part  of  the  trachea,  removal  by  tracheotomy  may 
be  attempted. 

On  the  whole,  prognosis  is  not  favorable  without  treatment  by  a  special- 
ist. Secondary  broncho-pneumonia,  especially  in  little  children,  often 
causes  death. 


364  TEXT-BOOK  OF  PEDIATRICS 

PAPILLOMA  OF  THE  LARYNX 

Granulomata  of  the  larynx  may  be  observed  after  too  long  continued 
intubation,  due  to  decubitus.  In  the  middle  of  childhood,  small  nodules 
may  develop  on  the  vocal  cords  without  trauma.  They  are  usually  attrib- 
uted to  overexertion  of  the  vocal  cords  from  crying  or  singing  (singer's 
nodes)  and  are  probably  to  be  regarded  as  scrofulous  affections  of  the 
mucous  membrane  of  the  larynx.  They  cause  a  prolonged  hoarseness  and 
usually  disappear  spontaneoulsy  at  the  end  of  childhood. 

The  most  common  true  tumor  is  the  papilloma.  It  is  seated  usually  on 
the  true  vocal  cords,  produces  a  husky  or  hoarse  voice,  and  if  extensive, 
severe  dyspnoea.  The  diagnosis  can  be  made  only  be  means  of  a  laryngo- 
scopic  examination.  With  small  tumors,  one  may  wait  for  several  months 
for  spontaneous  healing.  In  most  cases  the  removal  by  the  endo-laryngeal 
way  is  indicated,  but  this  unfortunately  does  not  prevent  recurrences. 

THE  ACUTE    TRACHEOBRONCHITIS    OF  OLDER    CHILDREN 

One  of  the  most  common  illnesses  of  school  children  is  the  catarrhal 
affection  of  the  trachea  and  the  large  bronchi,  while  the  small  bronchi, 
which  in  infants  are  so  often  attacked,  remain  unaffected.  There  is  a 
swelling,  redness,  and  extensive  secretion  of  mucous,  which  beside  mild 
general  symptoms  causes  cough.  The  fever  is  high  for  one  or  two  days, 
then  gradually  subsides,  but  the  cough  remains  longer.  In  the  beginning  it 
is  hoarse  and  barking;  later  with  an  increase  in  secretion,  it  becomes  looser. 
Inclination  to  cough  is  usually  more  pronounced  in  the  morning  after  arising 
and  in  the  evening  after  retiring,  and  lasts  until  several  thick  masses  of 
mucous  have  been  coughed  up.  The  sleep  may  be  disturbed  by  paroxysms 
of  coughing  lasting  several  hours,  which  exhaust  and  frighten  the  child. 
Auscultation  and  percussion  usually  gives  negative  findings,  except  for 
large  rales  over  the  trachea.  A  differential  diagnosis  must  be  made  from 
whooping-cough  and  tuberculosis.  If  the  tuberculin  reaction  is  negative 
the  prognosis  is  good;  with  a  positive  tuberculin  reaction,  it  is  less  so. 

The  treatment  consists  of  moist  compresses  on  the  thorax,  put  on  at 
night  with  a  dry  linen  cover  and  taken  off  the  next  morning.  As  long  as  the 
fever  lasts,  the  children  should  be  kept  in  bed  and  after  the  fever  is  gone,  if 
the  weather  is  cold,  they  should  be  kept  indoors  for  a  week.  For  the  cough 
an  expectorant  should  be  given  (codein  sulphate  0.1,  ammonii  chloridi  3.0, 
syrup  tolu  50.0,  aqua3  ad  100;  in  teaspoonful  doses). 

BRONCHITIS 

The  etiology  of  catarrhal  affections  of  the  middle  sized  bronchi  is  that  of 
rhinitis.  Here  it  must  be  mentioned  again  that  children  with  exudative 
diathesis  have  an  especial  inclination  to  recurrent  and  prolonged  bronchitis, 
without  ever  being  able  to  find  a  plausible  for  the  cause  of  this  anomaly. 
Similar  to  these  attacks  of  bronchitis  of  the  exudative  child  are  those  of  the 
rickitic  child.  These  children  often  have  for  a  long  time  a  loud  rattling 
sound  in  the  chest,  which  may  be  heard  at  a  distance  and  be  felt  by  the 


DISEASES  OF  THE  RESPIRATORY  ORGANS  365 

palpating  hand.  This  originates  in  the  large  bronchi  and  has  the  peculiarity 
of  not  being  associated  with  an  inclination  to  cough. 

Acute  bronchitis  is  not  only  closely  related  to  acute  rhinitis  but  easily 
passes  into  bronchiolitis  and  broncho-pneumonia.  Most  of  the  time  the 
entire  respiratory  system  is  affected,  but  medical  nomenclature  designates 
only  the  most  affected  part.  It  is  presupposed  that  in  severe  affections,  as 
in  broncho-pneumonia,  the  rest  of  the  mucous  membrane  is  also  involved, 
but  interest  centres  only  in  that  part  which  has  the  greatest  importance  in 
prognosis.  In  a  similar  way,  in  gastro-enteritis  of  children,  the  entire  tract 
is  affected,  and  only  rarely  an  affection  of  an  isolated  part  can  be  diagnosed. 

The  symptoms  of  acute  bronchitis  in  children-  are  first  of  all  cough  and 
fever;  the  sputum  which  in  adults  plays  an  important  role  in  the  diagnosis, 
is  not  expectorated  by  children,  but  swallowed. 

Only  toward  the  close  of  childhood  does  the  expectoration  of  sputum 
occur  spontaneously;  in  smaller  children  this  very  seldom  happens  and  then 
only  when  there  is  much  secretion  and  prolonged  illness.  Children  from 
four  to  five  years  who  cough  up  sputum  almost  always  suffer  from  tubercu- 
losis or  bronchiectasis  or  at  least  have  had  a  prolonged  attack  of  whooping 
cough.  If  one  wishes  to  examine  the  sputum,  one  must  take  a  small  wad  of 
cotton,  press  it  with  a  tweezer  against  the  back  wall  of  the  throat  until  a 
cough  results,  or  one  obtains  the  swallowed  sputum  by  aspiration  of  the 
empty  stomach  in  the  morning. 

In  acute  bronchitis  a  conclusion  as  to  the  type  of  secretion  can  be 
drawn  from  the  character  of  the  cough.  In  the  early  stages  as  long  as  there  is 
a  little  secretion,  the  cough  is  harsh  and  barking.  Later  with  the  increase  of 
secretion,  it  becomes  looser.  The  fever  may  be  of  varying  heights;  depend- 
ing on  the  infectious  agent,  the  temperature  varies  from  a  little  over  37°C. 
(98.6°F.)  up  to  40°C.  (103°F.)  or  more  and  may  be  very  irregular  at  different 
hours  of  the  day.  The  circulatory  system  usually  shows  nothing  striking 
with  the  exception  of  an  acceleration  of  the  pulse,  which  corresponds  to  the 
height  of  the  fever.  The  gastro-intestinal  tract  in  small  children  is  often 
sympathetically  affected.  In  the  beginning,  as  in  every  illness  with  tempera- 
ture there  is  slight  vomiting;  the  tongue  is  coated;  there  is  loss  of  appetite. 
Bad  stools  and  pain  in  the  epigastrium  are  symptoms  which  are  to  be 
explained  by  the  action  of  the  infective  agent  on  the  mucous  membrane  of 
the  intestines.  Older  children  have  headache,  lassitude,  and  sleeplessness 
caused  by  coughing. 

In  the  physical  examination,  auscultation  gives  coarse,  loud,  but  not 
sonorous  rales.  The  vesicular  breath  sounds  are  sharp,  the  expiration  pro- 
longed. Percussion  shows  no  peculiarities.  Holding  the  breath  for  some 
time  or  persistent  loud  crying  during  the  examination  are  favorable  signs. 
In  severe  affections  like  bronchiolitis  or  pneumonia,  it  is  not  possible  to 
hold  the  breath  long.  Uncomplicated  bronchitis  with  temperature  subsides 
usually  in  one  to  two  weeks. 

In  general  the  prognosis  of  simple  bronchitis  is  good  as  long  as  it  remains 
as  a  catarrh  of  the  large  bronchi;  with  higher  temperature  and  labored 
respiration,  the  prognosis  must  be  guarded,  as  it  can  always  end  in  broncho- 


366 


TEXT-BOOK  OF  PEDIATRICS 


pneumonia.  This  is  especially  true  in  infants;  in  older  children  the  danger 
of  broncho-pneumonia  is  not  so  great,  but  in  every  localized  bronchitis, 
the  possibility  of  tuberculosis  must  be  considered.  In  every  beginning  bron- 
chitis one  must  also  think  of  measles  and  pertussis.  In  measles  the  con- 
junctivitis soon  appears,  and  after  a  few  days  the  diagnostic  Koplik's 
spots;  with  pertussis  on  the  other  hand,  the  diagnosis  must  be  deferred 
eight  to  fourteen  days  until  the  typical  whoop  appears,  because  so  far  there 
is  no  other  way  of  establishing  the  diagnosis.  Severe  cough,  out  of  propor- 


FIG.  103 — Croup  kettle. 

tion  to  the  negative  or  slight  findings  on  auscultation,  and  lack  of  fever 
arouse  suspicion  of  a  beginning  pertussis. 

As  a  prophylaxis  against  bronchitis,  the  children  should  be  kept  away 
from  adults  who  have  coryza. 

An  infection  producing  only  nasal  and  throat  symptoms  in  adults,  when 
transmitted  to  children,  especially  infants,  may  cause  an  extensive  reaction 
of  much  greater  severity  and  longer  duration.  People  should  be  warned 
against  kissing  children,  or  coughing  or  sneezing  near  them. 

As  a  general  prophylaxis,  gradual  hardening  of  the  child  is  desirable  in 
order  that  it  may  be  able  to  withstand  changes  of  temperature  which  in 
delicate  children  favor  the  development  of  the  infection.  In  summer  the 
children  should  be  outdoors  as  much  as  possible,  and  at  night  the  window 
should  be  left  open.  Cold  sponges  are  advisable  in  strong  children  only 
and  then  with  water  at  room  temperature.  This  should  be  done  either  in 
the  morning  or  in  the  evening  before  going  to  bed  and  should  be  followed 
by  a  warm  rub. 


DISEASES  OF  THE  RESPIRATORY  ORGANS  367 

The  therapy  of  acute  bronchitis  is  similar  to  that  of  acute  coryza :  Rest  in 
bed  and  sweats,  as  well  as  wet  packs  which  should  be  warm  or  cool  depend- 
ing on  whether  or  not  the  child  has  fever.  In  bronchitis  with  temperature, 
chest  compresses  with  water  at  room  temperature,  and  renew  every  one  to 
two  hours,  are  useful. 

Such  a  compress  is  most  conveniently  applied  as  follows:  A  Turkish 
towel,  or  a  diaper,  long  enough  to  encircle  the  chest,  is  folded  so  that  its 
width  will  cover  from  the  axilla  to  the  umbilicus.  This  is  wrung  out  of 
water  of  the  desired  temperature  and  the  child  laid  in  the  centre  on  its  back. 
The  ends  are  brought  forward  under  the  arms  and  crossed  in  front  of  the 
chest,  passed  over  the  opposite  shoulder  and  pinned  to  the  part  of  the  towel 
covering  the  back.  The  whole  is  then  covered  with  a  dry  woolen  cloth  or 
with  oiled  silk  to  prevent  evaporation.  It  is  convenient  to  have  two  covers 
so  that  they  may  be  dried. 

Oil  may  be  used  for  hot  compresses.  For  this  purpose  a  large  flannel 
saturated  with  hot  oil  and  wrung  out  as  dry  as  possible  is  applied  in  the 
same  manner  as  the  moist  compress  described.  The  advantage  of  the  oil 
compress  is  that  it  does  not  dry  out  and  hence  holds  the  heat  better.  It  is, 
therefore,  best  adapted  for  use  in  those  cases  in  which  a  compress  is  to  be 
left  in  place  all  night. 

For  high  fever  warm  sponge-baths  or  tepid  (35°C.  or  90°F.)  tub  baths 
may  be  used.  Body  packs  with  water  at  room  temperature  in  which  the  pa- 
tient is  left  for  ten  to  fifteen  minutes  will  serve  to  reduce  high  temperatures. 
In  using  these  hydrotherapeutic  measures  great  care  must  be  exercised  to 
prevent  chilling.  Cyanosis  is  a  distinct  signal  for  their  prompt  interruption. 

The  air  of  the  sick-room  should  not  be  too  warm  and  should  be  kept 
damp.  It  is  of  great  importance,  especially  with  older  children,  to  humidify 
the  air  by  means  of  a  steam  kettle.  The  bronchitis  kettle  equipped  with  an 
alcohol  lamp  can  be  placed  beside  the  bed  and  is  very  practical  for  that 
purpose.  In  summer  the  open-air  treatment  is  excellent ;  in  winter  it  is  to  be 
used  with  care.  It  is  very  good  for  the  children  to  lie  outdoors  on  the 
veranda  on  sunny  days  even  in  cold  weather;  they  must,  however,  be  well 
wrapped  and  have  hot  water  bottles  around  them.  The  medical  exami- 
nation, meals,  and  changing  of  diapers  should  take  place  in  a  warm  room. 

For  the  medicinal  treatment  of  acute  bronchitis,  expectorants  are  com- 
monly used,  but  without  much  result.  For  extensive  rales,  ten  drops  of 
syrup  of  ipecac,  or  two  to  ten  drops  of  liquor  ammonii  anisati  in  sugar  water 
three  times  a  day,  or  finally,  creosote  carbonate,  0.5-1  drop  in  milk. 

For  few  rales  and  severe  inclination  to  cough,  give  children  from  six 
years  up,  morphin  (two  to  five  times  one  milligram)  internally.  Codein 
sulphate  can  be  given  to  children  over  two  years  of  age,  giving  one  centi- 
gram (%  gr.)  per  day  in  divided  doses. 

If  there  is  a  disturbance  of  the  digestion,  it  is  better  not  to  use  internal 
medication.  Especial  attention  must  be  given  to  the  diet  which  during 
the  time  of  the  fever  should  be  liquid  or  soft.  Later  gradual  return  to  the 


368  TEXT-BOOK  OF  PEDIATRICS 

usual  diet  is  permissible.  During  the  fever,  liquids  are  to  be  given  freely 
(lemonade,  weak  tea  or  milk  with  mineral  water). 

In  case  of  chronic  bronchitis,  if  a  change  of  air  (a  sojourn  at  the  sea  or 
in  the  mountains)  is  not  possible,  inhalations  of  hot  air  (Schmidt)  or  of  salt 
steam  (Mayerhofer)  may  be  used. 

This  latter  method  rests  on  the  following:  Chemically  pure  sodium 
chloride,  molten  at  1000  degrees  Centigrade,  gives  off  a  salt  vapor  and  a 
dense  fog  of  minutest  sodium  chloride  crystals.  This  sodium  chloride  fog  is 
exceedingly  mobile  and  hard  to  condense,  so  much  so  that,  for  example,  it 
can  be  blown  like  the  smoke  of  a  cigar,  through  water,  or  even  through  a 
silver  nitrate  solution  without  being  completely  destroyed,  although  a  part 
is  dissolved  or  reacts  with  the  silver  nitrate.  Contrary  to  the  usual  inhala- 
tions of  moist  steam,  the  sodium  chloride  fog  penetrates  into  the  finest 
alveolae  of  the  lungs,  and  there  produces  the  strongest  possible  sodium 
chloride  irritation. 

During  such  an  inhalation,  for  example,  the  character  of  the  rales  is  so 
changed  that  after  ten  minutes  instead  of  dry  rales,  moist  ones  can  be 
heard  (Mayerhofer).  The  necessary  apparatus  can  easily  be  constructed 
by  any  chemist. 

ASTHMATIC  BRONCHITIS 

In  the  discussion  of  the  etiology  of  acute  coryza,  hay  fever,  in  which 
the  rhinitis  is  caused  by  pollen,  has  been  mentioned.  A  similar  condition, 
the  cause  of  which  is  still  unknown,  develops  in  the  bronchi.  This  disorder 
occurs  chiefly  in  neuropathic  children  with  an  exudative  diathesis,  and 
especially  if  they  have  or  have  had  a  chronic  eczema.  The  past  history  of 
these  children  shows  that  they  have  had  bronchitis  frequently,  even 
during  the  first  year,  and  that  they  have  had  eczema  of  the  scalp  and 
cheeks  or  lichen  strophulus. 

With  every  recurring  attack  of  bronchitis  in  such  children,  more  and 
more  definite  signs  of  labored  respiration  without  obstruction  in  the  larynx 
gradually  become  noticeable.  This  respiratory  embarrassment  resembles 
the  asthma  of  adults.  At  the  age  of  six  to  ten  years  these  children,  other- 
wise strong  and  well-nourished  or  even  over-nourished,  regularly  at  the 
beginning  of  each  winter,  develop  a  slight  febrile  cough.  If  a  first  attack 
has  disappeared  and  the  child  goes  out  during  cold  weather  or  is  exposed  to 
high  winds,  the  cough  reappears  and  may  continue  for  weeks.  With  short 
intervals  of  relief,  this  may  go  on  during  the  whole  winter.  Expiration 
becomes  more  and  more  difficult.  The  child  raises  himself  from  the  bed,  and 
the  breathing  is  wheezing  and  labored.  The  convulsive  cough  brings  up 
only  a  little  tenacious  sputum.  Physical  examination  shows  a  well-formed 
and  very  deep  thorax  persistently  in  the  phase  of  inspiration  and  with  small 
respiratory  excursions.  Percussion  gives  increased  resonance  over  the  en- 
tire lung,  and  auscultation,  many  coarse,  piping  rales.  Eosinophilic  cells  are 
always  found  in  the  sputum.  Charcot  Leyden  crystals  and  Curschmann's 
spirals  are  rarely  discovered  in  children. 


DISEASES  OF  THE  RESPIRATORY  ORGANS  369 

The  prognosis  is  favorable.  The  attacks  usually  disappear  in  the  spring, 
but  tend  to  reappear  at  the  slightest  exposure  during  the  next  winter. 

In  making  a  differential  diagnosis,  tuberculosis  is  to  be  considered 
first  of  ah1,  particularly  in  small  children.  In  infancy  expiratory  asthma  is 
due  in  many  cases  to  tuberculous  swelling  of  the  bronchial  glands.  In  this 
event  the  prognosis  is,  of  course,  grave. 

With  negative  tuberculin  reaction,  and  in  older  and  stronger  children,  a 
diagnosis  of  asthma  is  justified.  If  permanent  recovery  is  to  be  secured, 
the  neuropathic  factor  must  be  taken  into  account. 

With  older  children  the  best  results  are  to  be  obtained  by  a  change  of 
climate.  In  the  matter  of  choice  it  makes  little  difference  whether  the 
patient  be  sent  to  the  sea-shore,  to  the  mountains,  or  merely  into  the  country. 
The  main  thing  is  to  convince  him  that  he  can  breathe  more  freely  in 
another  atmosphere,  so  that  he  may  lose  the  fear  of  the  attack  and  the 
expectation  of  the  cough.  If  a  climatic  change  is  not  possible  or  if  it  fails, 
breathing  exercises  may  be  instituted.  Several  times  a  day  the  thorax 
should  be  compressed  in  expiration  for  a  few  minutes. 

Kuhn's  mask  is  usually  borne  very  well  by  children.  The  apparatus 
lessens  the  ease  of  inspiration,  and  this  draws  the  blood  to  the  lungs. 

Hydrotherapeutic  procedures  by  way  of  the  cold  sponge  or  douche  are 
at  times  successful. 

As  a  further  means  of  relief,  a  complete  change  of  diet  serves  as  effec- 
tively as  in  a  chronic  eczema.  Children  accustomed  to  taking  large  quanti- 
ties of  milk  should  discontinue  it  in  favor  of  a  mixed  diet.  A  salt-free  or  a 
fat-free  diet  may  be  tried  also.  Expectorants  or  sedatives  are  required 
during  the  acute  attacks.  Codein  (0.005-0.02  gm.)  or  morphin  in  one 
milligram  doses  (gr.  ^£0)  for  each  year  of  age  may  be  used.  If  necessary 
an  enema,  containing  0.3  gm.  of  chloral  hydrate  in  30  gms.  of  mucilage  of 
acacia  may  be  given. 

Sodium  iodide  is  recommended  for  continuous  treatment.  It  may  be 
given  in  the  following  formula: 

Gms. 

R   Sodii  iodid 1 (gr.  xx) 

Syrupi  simplicis 10 (3  ii) 

Aquae  destillatae  ad 100 (3  iv) 

M.  Sig. — Two  teaspoonfuls  each  day. 

Larger  doses  may  be  given  in  the  proportion  of  one  gram  to  each  year 
of  the  child's  age,  in  100  c.c.  of  water,  to  be  given  in  doses  of  one  tablespoon- 
ful,  in  milk,  after  the  noon  and  evening  meal. 

Asthmatic  conditions  in  children  are  frequently  the  expression  of  their 
sensitization  to  foreign  proteins.  The  younger  the  child  the  more  often  food 
proteins  are  at  fault.  (Walker  and  others.)  Of  these,  according  to  the  skin 
tests,  eggs  and  cereals  are  the  most  frequent  offenders. 

This  sensitization  may  be  due  to  inhalation  through  the  respiratory 
tract,  ingestion  into  the  gastro-intestinal  tract,  which  may  be  permeable 
for  undigested  foods  (Schloss  and  Worthen),  absorption  from  the  skin  or 
conjunctivas,  and  infection  anywhere  in  the  body,  particularly  the  so-called 
foci  of  infection,  as  tonsils,  teeth,  etc. 
24 


370  TEXT-BOOK  OF  PEDIATRICS 

In  the  differential  diagnosis  of  asthmatic  conditions  the  skin  test  plays 
an  important  role.  Not  only  food  proteins,  but  also  animal  emanations  and 
bacterial  proteins  must  be  considered. 

In  the  treatment  of  the  attack  the  subcutaneous  injection  of  0.2-0.3  c.c. 
of  adrenalin  chloride  solution  (1-1000)  repeated  if  necessary  gives  the 
best  results. 

The  dietary  treatment  requires  omitting  the  food  at  fault,  and  diminish- 
ing non-specific  protein  to  the  minimun. 

The  desensitization  of  the  patient  by  the  feeding  of  minimal,  gradually 
increasing,  amounts  of  the  food  at  fault  seems  to  be  followed  by  success  in 
some  cases. 

The  removal  of  the  foci  of  infection  is  essential. 

The  value  of  vaccines  is,  to  say  the  least,  doubtful. 

CAPILLARY  BRONCHITIS 

A  purulent  catarrhal  inflammation  of  the  smallest  bronchioles  is  a  form 
of  bronchitis  common  in  infancy  and  hardly  ever  seen  in  later  years.  Most 
of  these  cases  occur  between  six  and  eighteen  months  of  age.  This  is  also 
the  period  of  florid  rickets.  As  an  actual  fact,  this  form  of  bronchitis  is  so 
frequently  seen  in  severely  rickitic  children  that  causal  relationship  must  be 
suspected.  Whether  this  relationship  depends  upon  the  mechanical  con- 
ditions of  the  soft  rickitic  thorax,  which  prevents  ventilation  of  the  bronchi- 
oles or  whether  the  mucous  membrane  of  the  bronchioles  is  in  itself  injured 
by  rickets,  cannot  be  determined.  The  etiology  of  capillary  bronchitis  is 
no  more  specific  than  that  of  coryza.  Frequently  the  disease  develops 
during  pertussis  or  measles,  and  still  more  frequently  with  influenza. 
Most  often  it  is  seen  as  a  secondary  infection  by  the  influenza  bacillus,  fol- 
lowing measles;  and  it  is  supposable  that  a  bronchial  catarrh  may  spread 
from  the  larger  to  the  smaller  bronchi  by  a  secondary  infection. 

The  clinical  difference  between  this  disease  and  broncho-pneumonia  is 
is  not  always  a  very  distinct  one,  but  pathologically  the  differentiation  is 
very  clear.  At  autopsy,  the  lung  is  found  to  contain  air  throughout ;  it  is  a 
light  red  in  color  and  without  compression  of  its  lobules.  If  pressure  is 
made  upon  a  cut  surface,  innumerable  droplets  of  pus  exude  from  the  small- 
est bronchioles.  The  mucous  membrane  of  these  minute  air  passages  isbright 
red,  swollen,  and  covered  with  mucopus. 

A  microscopic  examination  shows  the  vessels  filled  with  blood  clots  and 
the  bronchioles  plugged  with  mucous,  polynuclear  leucocytes  and  epithe- 
lium. The  alveoli  are  almost  entirely  clear  and  even  abnormally  expanded. 
The  walls  of  the  bronchi  and  the  interstitial  connective  tissue  show  small 
cell  infiltration. 

These  classical  findings,  however,  occur  only  in  those  cases  that  die 
very  shortly  after  the  onset  of  the  disease.  After  the  closure  of  the  bronchi- 
oles has  existed  for  a  longer  period,  secondary  changes  appear.  Foci  of 
lobular  infiltration  are  found  here  and  there,  resulting  from  the  aspiration 
of  pus  into  the  alveoli  or  from  the  extension  to  them  of  the  inflammatory 
process.  Atelectases  and  partial  emphysema  develop.  The  distention  of 


DISEASES  OF  THE  RESPIRATORY  ORGANS  371 

certain  parts  of  the  lung  may  be  explained  by  the  fact  that  the  air  is 
pumped  in  with  inspiration  but  its  expression  through  the  narrowed  tubes 
is  imperfect.  In  these  regions,  gradual  absorption  of  the  air  takes  place,  and 
these  areas  become  dark  brown  and  atelectatic.  The  atelectases  occur 
chiefly  in  the  posterior  dependent  parts,  and  the  emphysema  in  the  ante- 
rior portions  of  the  lung.  The  pleura  is  negative  and  other  organs  show 
only  congestion. 

The  clinical  picture  develops  very  rapidly.  The  disease  is  usuall  se- 
quent to  an  old  bronchial  catarrh.  The  first  symptoms  are  high  fever  and 
labored  respiration,  followed  by  a  very  characteristic  condition;  an  acute 
pallor,  especially  noticeable  in  children  who  previously  had  good  color. 
Later,  a  bluish  tinge,  due  to  cyanosis,  mingles  with  the  pallor,  eventually 
resolving  itself  into  a  peculiar  grayish  hue. 

The  respirations  become  very  frequent  and  labored.  The  thorax  is 
held  spasmodically  in  the  inspiratory  phase,  but  only  a  small  amount  of 
air  enters.  Consequently,  the  normal  bulging  of  the  epigastrium  is  replaced 
by  retraction 

In  all  febrile  diseases,  excepting  tuberculous  meningitis,  the  respiration 
is  of  increased  frequency,  but  the  rate  is  never  so  markedly  increased  as  in 
capillary  bronchitis.  In  this  disease  it  maybe  increased  to  one  .hundred  or 
more  per  minute  and  out  of  proportion  to  the  pulse-rate.  While  under 
normal  conditions  the  ratio  of  heart-beats  to  one  respiration  is  three  or  four 
to  one,  in  capillary  bronchitis  the  ratio  is  two  to  one,  or  even  less.  The 
respirations  are  apt  to  be  accompanied  by  movements  of  the  alaenasi. 
The  expiration  is  convulsive,  and  whistling  rales  may  be  heard  at  a  distance. 
The  thorax  of  rickitic  children  will  change  its  form  with  each  respiration, 
especially  along  the  rosary  and  in  the  flanks.  At  the  outset  of  the  disease 
the  child  is  still  strong  enough  to  overcome  the  reduced  aeration  by  forced 
efforts,  but  later  the  strength  fails,  and  the  respiration  becomes  more 
arid  more  frequent  and  superficial.  The  cough,  which  at  first  resembles 
attacks  of  pertussis,  becomes  gradually  weaker. 

The  physical  signs  are  in  the  beginning  comparatively  slight.  Percus- 
sion gives  a  clear,  deep  note  and  only  occasional  fine  bubbling  rales  can 
be  heard  on  auscultation.  In  spite  of  this,  tactile  fremitus  may  be 
reduced  on  account  of  the  plugging  of  numerous  bronchi  with  secretion. 
Later  the  r&les  become  general  and  an  indefinite  dulness  is  found  on  per- 
cussion over  the  back  and  especially  along  the  spine,  indicating  atelectasis 
or  beginning  pneumonic  foci.  The  former  disappears  on  deep  breathing  if 
the  patient  is  turned  upon  the  opposite  side  from  that  under  observa- 
tion. Anteriorly,  the  cardiac  dulness  is  usually  covered  by  parts  of  the 
distended  lungs. 

As  a  result  of  the  deficient  aeration  of  the  blood  and  the  lowering  of  the 
heart's  force,  cyanosis  becomes  more  and  more  marked,  and  the  extremities 
become  pallid  and  cold.  The  face,  too,  grows  strikingly  pale. 

As  in  all  acute  diseases  of  childhood,  the  nervous  system  gives  symptoms 
of  associated  disturbance.  Initial  vomiting  occurs,  also  extreme  restlessness, 


372  TEXT-BOOK  OF  PEDIATRICS 

and  very  frequently  general  convulsions  of  an  epileptiform  nature.  These 
disturbances  later  give  way  to  a  general  apathy. 

The  prognosis  of  capillary  bronchitis  is  always  very  grave.  Severe 
rickets  and  general  convulsions  must  be  considered  a  bad  omen.  Over 
50  per  cent,  of  clearly  defined  cases  die  within  a  few  days.  If  the  patient 
survives  the  first  week  without  the  development  of  lobular  pneumonia, 
there  is  some  hope  of  recovery. 

The  diagnosis  is  based  mainly  on  the  dyspnoea,  without  definite  physi- 
cal findings.  The  disease  is  not  always  distinguishable  from  an  early 
broncho-pneumonia  or  from  a  lobar  pneumonia.  Later  in  its  course  aus- 
cultation will  determine  whether  there  is  consolidation  of  lung  tissue.  In 
children  having  signs  of  tuberculosis  or  scrofula,  miliary  tuberculosis  must 
be  considered.  A  positive  differentiation  is  difficult  because  the  tuberculin 
reaction  often  fails  in  miliary  tuberculosis.  The  Roentgen  picture  may 
enable  one  to  make  the  distinction. 

The  dyspnoea  may  be  so  severe  as  to  suggest  an  obstruction  of  the 
larynx  incident  to  a  diphtheritic  or  false  croup.  If  the  tonsils,  nose,  and 
nasopharynx  are  clear,  diphtheria  will  hardly  be  present.  If  a  constriction 
due  to  false  croup  is  suspected,  intubation  may  be  tried.  If  this  does  not  give 
relief,  the  trouble  lies  farther  down  in  the  small  bronchi. 

The  therapy  is,  at  first,  that  of  bronchitis  in  general  in  the  way  of  sweats, 
warm  packs,  expectorants,  or  emetics  (see  p.  367) .  When  the  dyspnoea  be- 
comes intense  and  general  pallor  appears,  a  mustard  bath  is  indicated.  This 
has  its  disadvantage,  however,  in  the  fact  that  the  irritating  volatile  oil  of 
mustard  affects  not  only  the  skin  but  the  air  passages  as  well.  For  this 
reason  Heubner  advocates  the  mustard  pack.  This  is  prepared  as  follows  : 
A  cupful  of  ground  mustard  is  mixed  to  a  smooth  paste  with  a  little  cold 
water  and  this  paste  is  stirred  into  a  quart  or  more  of  boiling  water  in  an 
open  basin.  A  towel  or  sheet  large  enough  to  completely  enfold  the  patient 
is  wrung  out  of  this  mustard  water  and  spread  upon  a  woolen  blanket  and 
quickly  wrapped  around  the  patient.  Because  of  the  irritation  due  to 
inhalation  of  the  mustard  vapors  it  is  well  to  hold  a  wet  cloth  over  the 
patient's  nose  and  mouth.  The  pack  is  then  surrounded  by  hot  water 
bottes  and  left  in  place  for  fifteen  minutes  to  one-half  hour.  If  the  child 
reacts  it  will  soon  become  restless  and  begin  to  cry.  It  has  been  found 
advantageous  to  give  oxygen  inhalations  or  place  the  patient  near  an  open 
window  or  even  stick  the  child 's  head  out  of  an  open  window  during  these 
deep  respirations. 

A  satisfactory  reaction  is  achieved  when  the  skin  becomes  bright  red 
wherever  the  pack  touched.  As  soon  as  this  desired  result  is  obtained 
the  pack  is  removed,  the  patient  sponged  to  remove  all  particles  of  mustard 
from  the  skin,  and  then  wrapped  in  a  further  tepid  pack  \vith  a  clean  cloth 
wrung  out  of  plain  water.  This  latter  is  left  in  place  for  one  to  two  hours, 
when  it  is  removed,  the  skin  dried  and  gently  rubbed  with  olive  oil  or 
cocoa  butter.  The  temperature  often  rises  during  this  procedure  and  after 
it  is  completed  the  patient  should  be  put  in  bed  and  not  disturbed  for 
several  hours. 


DISEASES  OF  THE  RESPIRATORY  ORGANS  373 

The  failure  of  the  mustard  pack  to  redden  the  skin  is  a  bad  prognostic 
sign.  A  distinct  improvement  is  often  seen  in  a  few  hours  after  an  intense 
reaction  of  the  skin.  The  mustard  pack  may  be  given  once  a  day.  In  mild 
cases,  in  which  this  treatment  would  be  too  severe,  since  there  is  always 
some  danger  of  collapse,  a  hot  bath  with  douches  will  suffice. 

Heart  stimulants  should  also  be  employed.  Digitalis,  or  one  of  its  deriva- 
tives, may  be  used;  or  in  cases  of  long  duration,  tincture  of  strophanthus;  or 
in  acute  relapses,  injections  of  camphor  or  caffein  may  be  tried.  (See  cardiac 
diseases,  broken  compensation.) 

In  very  severe  cases,  venesection  may  be  employed.  This  is  quite  a 
difficult  procedure  in  small,  fat  children.  The  attempt  should  first  be  made 
to  withdraw  blood  by  puncture. '  If  this  is  not  successful,  the  saphenous 
vein  must  be  exposed  by  dissection,  and  from  30  to  50  c.c.  (1-2  ounces)  of 
blood  withdrawn  from  it. 

Inhalations  of  oxygen  are  very  helpful  in  some  cases.  When  the  more 
acute/threatening  symptoms  have  disappeared,  the  treatment  is  the  same 
as  that  of  acute  bronchitis. 

Broncho-tetany. — Some  cases  of  asthma  and  capillary  bronchitis,  oc- 
curring at  the  age  when  florid  rickets  develop,  may  be  features  of  the 
disease-picture  of  broncho-tetany  recently  described  by  Lederer.  In  spas- 
mophilic  children  who  had  died  with  the  signs  of  acute  suffocation  or  even  of 
supposed  broncho-pneumonia,  he  has  found  no  evidences  of  pneumonia 
autopsy,  but  of  edema  or  atelectasis  instead.  He  suggests  that  tetanic 
contractions  of  the  bronchioles  may  have  caused  the  symptoms  in  question. 
Early  indications  of  dyspnoea  in  rickitic  and  spasmophilic  patients  should 
be  treated,  therefore,  with  calcium  salts  in  the  form  of  calcium  lactate 
(1.0-5.0  gms.)  each  day.  (Rietchel,  Curschmann.) 

BRONCHO-PNEUMONIA 

(  In  most  instances  an  inflammation  does  not  confine  itself  to  the  small 
bronchi  but  invades  the  alveoli.  At  first  the  air-cells  are  filled  with  mucous, 
but  later  an  infiltration  of  the  interstitial  tissue  occurs.  The  numerous 
small  foci  of  infiltration  soon  become  more  or  less  confluent.  Pathologically 
whitish-yellow  miliary  areas  are  found  at  the  very  outset.  On  section  these 
discharge  a  purulent  fluid.  Later,  reddish-brown  indurations,  varying  in 
size  from  that  of  a  pea  to  a  small  nut,  are  observed.  If  the  process  continues 
wedge-shaped  foci  appear  which  may  eventually  involve  the  entirb  lobe. 
The  borders  of  the  lungs  are  emphysematous,  and  atelectases  are  formed 
where  portions  of  the  bronchi  are  obstructed  by  the  secretion  or  compressed 
by  pneumonic  foci  in  the  neighboring  tissue.  According  to  the  extent  of  the 
area  affected,  two  types  of  broncho-pneumonia  are  to  be  distinguished,  the 
disseminate  and  the  pseudo-lobar  forms. 

Bacteriologically,  numerous  organisms  are  productive  of  the  disease. 
Among  the  more  common  are  the  diploccus  pneumonije,  the  diplococcus 
catarrhalis  and  the  influenza  bacillus.  Again,  pneumonias  occur  in  young 
infants  and  especially  in  atrophic  nurslings,  in  whom  no  micro-organism 
is  found.  These  forms  are  afebrile  and  simply  hypostatic. 


374  TEXT-BOOK  OF  PEDIATRICS 

Aspiration  pneumonia  has  a  much  more  serious  course.  This  condition 
may  arise  during  the  first  few  days  of  life  as  a  result  of  the  aspiration  of 
amniotic  fluid.  It  also  occurs,  as  in  adults,  following  severe  exhaustion, 
as  for  instance  in  typhoid  fever.  Aspiration  pneumonia  is  frequently  a 
result  of  diphtheritic  paralysis.  Since  the  larynx  is  not  efficiently  closed 
on  account  of  the  paralysis  of  the  epiglottis,  and  since  effective  coughing  is 
impossible  because  of  the  incomplete  closure  of  the  vocal  cords,  fluids  often 
enter  the  bronchi  and  cause  pneumonia.  This  occurs  more  readily  when 
there  is  coincident  cardiac  weakness. 

Broncho-pneumonia  is  a  very  serious  complication  of  measles.  It  is 
probable  that  all  infectious  organisms  find  a  very  fertile  soil  in  the  child  ill 
with  measles,  since  the  antibodies  of  various  bacteria,  like  those  of  the 
bacillus  tuberculosis,  are  unable  to  maintain  their  normal  activity  during  its 
acute  stage.  Pneumonia  usually  sets  in  after  the  disappearance  of  the 
rash  and  is  first  announced  by  the  renewal  of  fever  and  the  development 
of  dyspnoea. 

Pertussis,  like  measles,  is  not  usually  in  itself  a  dangerous  disease;  its 
fatality  depends  upon  a  complicating  pneumonia.  In  scarlet  fever,  on  the 
other  hand,  pneumonia  is  extremely  rare.  When  it  does  occur  it  has  a 
rapidly  fatal  termination. 

Rickets  has  no  direct  influence  upon  the  occurrence  of  broncho-pneu- 
monia, but  it  does  tend  to  make  the  prognosis  of  coexisting  pulmonary 
disease  the  more  unfavorable.  This  is  probably  due  to  the  mechanical 
difficulties  it  occasions  in  respiration. 

The  Clinical  Picture. — When  broncho-pneumonia  is  not  imposed  as  a 
complication  upon  a  preexisting  catarrh  of  the  respiratory  passages  or  upon 
the  course  of  an  infectious  disease,  its  onset  may  be  either  sudden  and 
attended  by  vomiting  and  fever,  or  it  may  be  gradual.  The  vomiting  soon 
stops,  but  anorexia  follows.  The  fever  is  continuous  as  in  lobar  pneumonia, 
but  usually  recedes  in  the  morning,  and  reaches  39°-40°  C.  (102°-104°F.) 
in  the  evening.  The  pulse  is  increased  proportionately  to  the  temper- 
ature, but  the  respiratory  relationship  is  disturbed,  showing  an  abnormally 
high  frequency.  Early,  the  respiration,  and  especially  the  expiratory  move- 
ment, becomes  labored.  The  ala?  nasi  and  the  auxiliary  thoracic  muscles 
are  soon  brought  into  action. 

Physical  .examination  shows,  at  first,  only  a  few  scattered  rales,  but  as 
the  disease  progresses,  these  grow  more  numerous,  louder,  and  more 
ringing.  Expiration  becomes  bronchial  in  character,  and  finally  distinct 
bronchial  breathing  and  subcrepitant  rales  are  heard. 

The  physical  signs  are  most  frequently  found  first  at  the  lower  borders 
of  the  lungs  and  between  the  scapula?.  It  is  not  long  before  rales  are  heard 
all  over  the  lower  lobes.  Here  and  there  incBcased  breath  sounds,  evidenc- 
ing infiltration,  may  be  heard  in  distinctly  circumscribed  areas.  In  the 
course  of  a  day  or  two,  one  or  both  lobes  are  infiltrated,  when  bronchial 
breathing  and  segophony  are  found.  The  anterior  surfaces  are,  as  a  rule, 
clear,  but  rales  are  eventually  heard  over  the  entire  lung.  Percussion  may 
be  at  times  entirely  negative,  or  only  slight  dulness  and  tympany  are  ap- 


DISEASES  OF  THE  RESPIRATORY  ORGANS  375 

parent.  Generally  a  relative  dulness  running  along  the  vertebral  column 
may  be  recognized.  The  Roentgen  picture  shows  disseminated  shadows 
representing  the  infiltrated  areas. 

The  clinical  picture  of  broncho-pneumonia  is  not  constant.  Cases  are 
observed  in  which  there  is  only  a  slight  fever,  with  small  foci  of  infection 
and  accordingly  little  disturbance  of  general  health.  On  the  other  hand, 
with  quite  similar  findings,  the  patient  may  be  completely  prostrated,  and 
death  speedily  ensues.  Again  there  are  cases  which  from  their  onset  are 
attended  by  high  fever,  great  restlessness,  diarrhoea  and  early  unconscious- 
ness, with  rapidly  spreading  infiltration  of  the  lower  lobes,  and  ending 
fatally  in  a  very  short  time. 

In  consequence  of  the  disturbed  function,  a  small  and  very  frequent 
pulse  and  cyanosis,  especially  at  the  finger  tips,  are  observed.  The  urine  is 
diminished  in  quantity  and  contains  albumen.  The  intestinal  tract  may  be 
affected  with  resulting  diarrhoea,  muco-sanguineous  stools  and  meteorism, 
accompanied  by  a  high  position  of  the  diaphragm. 

The  prognosis  depends  essentially  upon  the  area  of  infiltration  and  is 
difficult  to  forecast.  The  age  of  the  patient  is  an  important  matter. 
Broncho-pneumonia  is  especially  common  and  most  to  be  dreaded  between 
six  months  and  two  years,  as  is  shown  in  the  following  table : 

FREQUENCY  AND  MORTALITY  OF  BRONCHO-PNEUMONIA  DURING 
EARLY  CHILDHOOD  (Holt). 

Age.  No.  of  Per  Mortality 

Cases  cent.  Per  cent. 

During  first  year 224 53 66.  . . 

During  second  year 142 33 55 ... 

During  third  year 46 11 33.  .. 

During  fourth  year 10 2 16.  .. 

During  fifth  year 4 1 

(  In  the  first  year  feeble  children  react  to  the  disease  very  much  as  old 
people  do.  By  simply  lying  on  the  back,  they  may  acquire  a  hypostatic 
pneumonia  which  is  localized  in  a  border  of  infiltration  on  both  sides  of  the 
vertebral  column  (the  para  vertebral  pneumonia  of  Gregor). 

In  the  differential  diagnosis,  broncho-pneumonia  is  to  be  distinguished 
from  bronchitis  by  its  auscultatory  signs.  Both  lobar  pneumonia  and  pul- 
monary tuberculosis  are  to  be  excluded.  The  latter,  in  its  onset,  some- 
times resembles  a  diffuse  bronchitis  with  pneumonic  respiratory  qualities. 

Treatment. — Therapeutically,  the  most  important  item  of  treatment  in 
pneumonia  is  to  see  to  it  that  the  child  is  carried  about  or  at  least  permitted 
to  sit  up  a  great  deal.  This  is  equally  important  as  a  matter  of  prophylaxis 
if  the  child  has  bronchitis.  Extraordinary  results  may  be  obtained  by 
proper  feeding  and  care.  Nursing  infants  should  be  kept  on  breast  feeding. 
It  is  because  of  these  safeguards  that  complete  recovery  from  broncho- 
pneumonia  is  often  made  in  homes  of  poor  if  the  mother  can  devote  herself 
entirely  to  the  care  of  the  sick  child,  while  pneumonia  patients  in  the  best 
equipped  hospitals  die  if  the  nursing  force  is  inadequate. 

The  treatment  of  broncho-pneumonia  consists  chiefly  of  hydrothera- 
peutic  measures.  In  contradistinction  to  capillary  bronchitis,  in  which  the 


376  TEXT-BOOK  OF  PEDIATRICS 

mustard  pack  is  used,  the  Priessnitz  pack,  with  -water  at  room  temperature 
and  frequently  changed,  or  warm  baths  combined  with  cold  douches,  are 
used  in  this  disease.  The  bath  should  be  given  at  about  37°  C.  (98.6°  F.) 
and  the  water  for  the  cold  douches  at  about  25°  C.  (77°  F.).  After  the 
bath  the  child  should  be  rubbed  with  a  warmed  bath  towel  and  put  back 
into  the  previously  warmed  bed.  These  baths  may  be  repeated  three 
times  a  day,  if  necessary,  provided  the  patient  does  not  show  signs  of  ex- 
haustion. To  safeguard  the  occurrence  of  collapse,  an  analeptic  may  be 
given  before  the  bath,  in  the  form,  for  instance,  of  a  few  drops  of  brandy 
in  tea  or  coffee. 

In  broncho-pneumonia,  warm  baths  (35°  C.)  or  even  hot  baths  (up  to 
42°  C.)  are  very  beneficial.  Cool  baths  in  delicate  and  weak  children  lead 
to  cyanosis,  increase  of  the  pulse-rate,  cold  extremities,  and  general  prostra- 
tion while  hot  baths,  even  in  fever,  have  a  beneficial  and  quieting  influ- 
ence. (Feer.) 

The  inhalation  of  oxygen  gives  very  good  results  in  some  cases,  especially 
if  dyspnoea  and  cyanosis  are  present.  The  pulse  improves,  and  the  color 
becomes  rosier  if  the  child  inhales  the  oxygen  well.  A  difficulty  in  the  use 
of  this  method  however  is  the  tendency  to  tire  the  child  in  the  attempt  at 
inhalation.  An  older  child  may  be  permitted  to  take  the  glass  tip  of  the 
tube  in  his  mouth.  With  younger  children  the  gas  is  passed  over  the  face 
from  an  inverted  funnel,  or  a  specially  constructed  mask. 

Medicinal  measures  have  a  very  slight  influence  upon  the  course  of  the 
disease.  It  is  customary  to  give  such  mild  expectorants  as  ipecacuanha, 
senega,  liquor  ammoniae  anisati,  etc.  Cardiac  remedies  are  of  more  value 
in  the  event  of  threatened  heart  failure.  Camphorated  oil,  caffein,  and 
more  especially  digitalis  may  be  effective.  Digitalis  is  best  given  in  the 
form  of  the  infusion,  in  doses  of  0.6  c.c.  for  a  period  of  two  days ;  or  as  digalen 
in  doses  of  one  drop  for  each  year  of  age,  three  times  a  day.  (See  also  the 
therapy  of  cardiac  insufficiency.) 

LOBAR  PNEUMONIA 

The  acute  inflammation  of  the  lungs  chiefly  characterized  by  infiltration 
of  a  single  lobe  and  by  a  typical  temperature  curve  has  received  various 
names.  It  is  known  as  fibrinous,  lobar,  croupous,  massive,  and  pleuro- 
pneumonia.  Not  one  of  these  terms  f ully  covers  the  peculiar  features  of  the 
disease.  In  America,  lobar  pneumonia  is  the  designation  most  widely 
adopted,  while  in  Germany,  the  term  croupous  pneumonia  is  more  gener- 
ally used. 

Bacteriological ly  and  pathologically,  the  course  of  the  disease  in  children 
is  identical  with  that  in  adults;  and,  therefore,  it  will  not  be  necessary  to 
discuss  these  details  here.  Clinically  however,  lobar  pneumonia  presents  a 
number  of  peculiarities  in  children.  Formerly  the  disease  was  supposed 
to  be  very  rare  in  childhood;  but  this  remains  true  only  in  the  first  few 
months.  It  is  never  observed  before  the  third  month,  and  after  that  period 
its  frequency  increases  rapidly,  reaching  its  maximum  incidence  between 
the  second  and  the  fifth  years.  The  following  table  shows: 


DISEASES  OF  THE  RESPIRATORY  TRACT  377 

THE  FREQUENCY  OP  LOBAR  PNEUMONIA  DURING  THE  VARIOUS  PERIODS  OF  CHILDHOOD 

(Holt) 

Ages  Cases  Percentage 

During  1st  year 76 15 

From  2nd  to  6th  year 309 62 

From  7th  to  llth  year 104 21 

From  12th  to  14th  year 11 2 


Total 500 100 

The  frequency  varies  greatly  from  season  to  season.  The  disease  is  at  a 
minimum  early  in  the  autumn  and  at  its  maximum  in  the  spring.  At  times 
exposure  to  cold  or  some  direct  traumatic  influence  seems  to  stand  in  direct 
causal  relation  to  the  development  of  pneumonia  which,  as  in  coryza,  may 
be  charged  to  temporary  reduction  of  the  resistance  of  the  body. 

Lobar  pneumonia  is  most  frequently  localized  in  the  right  upper  lobe  or 
in  one  of  the  lower  lobes.  In  950  cases  in  children  under  fourteen  years  of 
age,  Holt  found  the  distribution  of  the  disease  in  the  lungs  as  follows : 

Seat  of  the  Disease.  No. 

Right  lung, 

upper  lobe  only 176 

middle  lobe  only 12 

lower    lobe  only 168 

more  than  one  lobe   77 

Total,  right  lung 7433 

Left  lung, 

upper  lobe  only 93 

lower  lobe  only 263 

more  than  one  lobe    38 

Total,  left  lung 7394 

Both  lungs, 

upper  lobes 13 

lower  lobes 41 

variably  localized 69 

Total,  both  lungs .123 

In  older  children,  the  disease  begins,  as  in  adults,  with  a  chill  and  with 
pain  in  the  side.  In  younger  children,  the  onset  is  not  always  so  distinct, 
and  the  chill,  in  particular,  is  not  often  marked.  On  the  other  hand,  those 
initial  symptoms  that  usually  usher  in  all  severe  affections  in  childhood,  such 
as  vomiting  or  convulsions,  are  common.  Sudden  vomiting  without  diar- 
rhoea or  a  history  of  previous  overfeeding  is  a  warning  signal  that  should 
find  one  prepared  for  almost  anything.  Scarlet  fever,  tuberculous  menin- 
gitis, pleurisy  or  pneumonia  may  be  announced  in  this  manner.  It  requires 
a  careful  examination  to  determine  from  what  special  site  this  one  symptom 
is  provoked. 

Another  difference  lies  in  the  fact  that  while  in  the  adult  the  pain  is 
referred  to  the  side,  in  the  child  it  is  replaced  by  abdominal  pain.  Young 
children  localize  pleural  and  all  other  thoracic  pain  in  the  abdomen.  This 
is  a  point  to  be  remembered,  since  the  cause  of  all  abdominal  pains  cannot 
be  found  there.  Not  infrequently  appendectomies  have  been  done  in  vain, 
when  the  pain  which  led  to  a  diagnosis  of  appendicitis  was  really  caused  by 
pneumonia  or  pleurisy. 


378 


TEXT-BOOK  OF  PEDIATRICS 


Aside  from  the  abdominal  pain,  an  expiratory  grunt  is  typical  of  lobar 
pneumonia  in  small  children.  This  symptom  is  even  more  prominent  in  this 
disease  than  it  is  in  broncho-pneumonia.  While  this  slight,  non-stridulous 
sound  is  produced  with  every  expiration,  the  inspirations  are  silent. 

The  sputum  that  older  children  sometimes  expectorate  is  glairy,  trans- 
parent, tenacious,  and  of  a  reddish-brown  color.  It  is,  at  times,  even 
mixed  with  blood.  When  placed  in  water  it  will  occasionally  show  dichoto- 
mously  branching  casts  of  bronchi.  As  resolution  occurs  the  sputum 
becomes  yellowish. 

The  lung  findings  in  childhood  are  not  so  distinct  as  in  the  adult.  The 
dulness  is  not  so  pronounced.  It  is  necessary  to  percuss  very  gently,  rely- 


FIG.  104. — Pneumonia  of  upper  right  lobe.     (Vienna  Children's  Hospital.) 

ing  more  upon  the  tympanitic  resonance  than  upon  the  shortening  of  the 
sound.  The  physical  findings  are  usually  not  clearly  apparent  until  two  or 
three  days  after  the  clinical  onset  of  the  disease.  Indeed  there  are  cases  in 
which  the  symptoms  become  manifest  only  after  the  fifth  or  sixth  day  and 
sometimes  not  until  crisis  occurs.  These  are  particularly  of  the  type  in 
which  the  pneumonic  infiltration  is  centrally  located  and  only  gradually 
approaches  the  pleura.  The  Roentgen  examination  renders  wonderful 
service  here.  By  its  aid  it  has  been  possible  to  show  that  pneumonia  begins, 
as  a  rule,  at  the  hilus  of  the  lung  and  spreads  thence  to  the  periphery. 

Auscultation  is  rather  more  difficult  than  it  is  in  the  adult.  The  child 
will  not  breathe  when  bidden,  or  may  even  hold  the  breath.  If  the  child 
cries,  the  respiration  is  more  intense,  but  the  inexperienced  observer  hears 
only  the  crying.  The  podiatrist  has  to  learn  to  use  these  crying  periods  for 
auscultation.  Over  infiltrated  areas  the  crying  or  sighing  has  an  entirely 


DISEASES  OF  THE  RESPIRATORY  ORGANS 


379 


different  sound  than  it  has  over  the  intact  lung.  The  sounds  seem  as  close 
to  the  ear  as  though  the  stethoscope  had  been  placed  over  the  trachea. 
During  inspiration  the  metallic  quality  of  the  rales  is  of  importance. 

If  the  foci  of  infiltration  are  very  small  or  are  centrally  located,  the 
the  changes  may  be  distinguished  only  by  the  auscultation  of  vocal  sounds 
over  the  various  portions  of  the  thoracic  wall.  Special  attention  should 
be  given  to  bronchophony  in  the  axilla  where  it  usually  occurs  earliest. 

Aside  from  the  type  of  respiration  and  the  high  and  continuous  fever, 
the  labial  herpes,  the  red  and  slightly  cyanotic  cheeks,  and  the  short  painful 
cough  are  points  which  aid  one  in  making  a  tentative  diagnosis  on  sight. 
True  herpes  is  not  constant,  nor  does  it  appear  early,  but  rather  at  the 
fastigium.  Frequently  there  is  a  subicteric  discoloration  of  the  skin.  At 
this  stage  the  patient  seems  very  low,  and  if  it  were  not  for  the  knowledge 
that  the  prognosis  of  lobar  pneumonia  is  very  favorable  in  childhood,  the 
general  appearance  might  suggest  that  death  is  actually  imminent.  For- 
tunately the  appearance  of  the  relieving  crisis  may  be  predicted  with  con- 
siderable certainty  at  this  point.  Free  perspiration  and  restful  sleep  may 
suddenly  take  the  place  of  the  distressing  symptoms,  and  within  twelve 
to  twenty-four  hours  the  temperature  may  fall  from  40°  C.  (104°  F.)  to 
the  normal,  or  to  subnormal  level.  Great  weakness  persists,  but  the  ap- 
petite improves,  and  within  a  few  days,  the  appearance  of  the  patient 
changes  completely. 

The  crisis  generally  occurs  on  the  seventh  day,  but  this  is  not  by  any 
means  constant,  as  is  shown  by  the  following  table : 

APPEARANCE  OF  CRISIS  IN  567  CASES  OP  LOBAR  PNEUMONIA  IN  CHILDREN.  (Holt.) 


Days  of  Illness. 

Number  of  Cases. 

Daya  of  Illness. 

Number  of  Cases. 

2 

3 

11 

18 

3 

22 

12 

7 

4 

43 

13 

8 

5 

88 

14 

1 

6 

83 

15 

1 

7 

132 

18 

3 

8 

73 

21 

1 

9 

55 

26 

1 

10 

22 

Cases  are  noted  in  which  the  crisis  occurs  very  early,  some,  indeed,  in 
which  the  disease  is  only  of  one  day's  duration.  (Feer.) 

The  physical  signs  do  not  keep  pace  with  the  clinical  findings  at  the 
period  of  crisis.  The  fine  crackling  rales  that  indicate  resolution  may  be 
delayed  for  several  days,  precisely  as  the  dulness  and  the  bronchial  breath- 
ing, in  exceptional  cases,  may  appear  only  after  the  crisis.  The  sudden  drop 
of  temperature  is  not  always  definite.  Pseudocrisis  is  almost  as  common 
as  crisis  itself,  a  renewed  rise  of  temperature  being  followed  later  by  the 
true  crisis.  More  rarely  the  termination,  in  the  event  of  pseudocrisis,  may 
be  lysis.  After  several  days  of  low  temperature,  a  reappearance  of  the 


380  TEXT-BOOK  OF  PEDIATRICS 

fever  may  indicate  the  involvement  of  another  lobe.  This  is  the  form  of 
so-called  pneumonia  migrans. 

In  most  cases,  not  only  the  parenchyma  of  the  lung  is  involved,  but  the 
inflammatory  process  reaches  the  pleura.  An  exudate  of  varying  extent  is 
formed,  which  may  be  either  serofibrinous  or  purulent.  Pneumonia  as  the 
chief  cause  of  empyema  will  be  discussed  later. 

The  pericardium  is  affected  in  a  similar  manner.  Pericarditis  of  this 
type  is  a  serious  complication  and  usually  fatal.  The  pericardial  exudate  is 
generally  not  very  large  and  the  friction  rub  is  obscured  by  the  pneumonic 
sounds  in  the  neighboring  lung  tissue.  On  this  account  pericarditis  is 
often  discovered  only  at  autopsy. 

Complicating  otitis  media  is  quite  frequent,  but  nephritis  is  exceptional. 

Endocarditis  is  extremely  uncommon,  and  the  heart  muscle,  which  so 
often  fails  in  the  adult,  is  unaffected  in  the  child.  Ninety-five  per  cent,  of 
pneumonias  in  childhood  survive  because  of  the  great  reserve  power  of  the 
heart,  while  over  thirty  per  cent,  in  the  adult  die  in  consequence  of  its  failure. 

Beside  the  pleura  and  the  pericardium,  distant  organs,  among  them 
the  joints,  the  bone-marrow  and  the  meninges,  are  at  times  affected  by 
the  diseases. 

Meningitic  symptoms  may  occur  when  the  pneumococcus  cannot  be 
found  in  the  cerebrospinal  fluid — that  is  without  actual  metastasis  of  the 
infection.  The  central  nervous  system,  in  fact,  takes  a  distinct  share  in  ths 
pneumonic  symptom-complex.  For  example,  aphasia  and  temporary 
hemiplegia  are  occasionally  seen  in  pneumonia  among  older  children.  At  an 
earlier  age,  convulsions  are  often  observed,  especially  at  the  onset  of  the 
disease.  It  is  important  that  the  meningeal  form  of  pneumonia  be  recog- 
nized. It  occurs  particularly  between  the  ages  of  three  and  seven  years. 
The  symptoms  begin  with  vomiting  and  headache.  Rigidity  of  the  muscles 
of  the  neck  and  transitory  strabismus  resemble  very  closely  the  conditions 
seen  in  epidemic  meningitis.  Coma  or  delirium  with  spastic  extremities  and 
hyperesthesia  of  the  skin  may  complete  the  picture.  If  pneumonia  is  found 
in  the  lower  lobe,  the  meningeal  symptoms  are  usually  regarded  as  evidence 
of  an  increased  severity  in  the  general  manifestations  of  the  disease  and 
nothing  more.  The  diagnostic  difficulties  are  much  greater  when  the  pneu- 
monia is  so  located  that  it  is  difficult  to  find,  as  for  instance  when  it  is 
located  in  an  upper  lobe.  Meningeal  symptoms  have  been  particularly 
emphasized  in  apical  pneumonias;  but  actually  they  seem  to  occur  with 
equal  frequency  in  pneumonias  otherwise  localized.  (Schlesinger.)  They 
have  no  serious  significance  and  disappear  with  the  crisis. 

The  differentiation  of  the  disease  from  broncho-pneumonia  is  unimport- 
ant from  a  therapeutic  standpoint,  but  it  is  undoubtedly  of  great  value 
in  prognosis  to  be  able  to  predict  crisis.  Special  attention  should  be  paid 
to  the  character  of  the  fever,  the  appearance  of  the  herpes,  and  the  locali- 
zation of  the  disease.  Infiltration  of  the  lower  lobe  with  coexisting  bron- 
chitis, speaks  for  broncho-pneumonia.  It  is  a  matter  of  experience  that 
a  great  variety  of  the  febrile  diseases  of  childhood  are  mistaken  for  pneu- 
monia. Among  these,  typhoid  fever,  meningitis,  and  pleuritis  may  be 


DISEASES  OF  THE  RESPIRATORY  TRACT  381 

especially  mentioned.  The  high  fever  and  the  rapid  respiration  are  usually 
responsible  for  these  errors.  Icterus  with  a  high  temperature  is  suggestive  of 
pneumonia.  In  this  disease  the  spleen  is  not  always  enlarged.  Frequently 
enlargement  is  found  only  after  crisis.  In  addition  to  the  physical  symp- 
toms, the  blood  and  the  urine  should  also  receive  attention.  Their  exam- 
ination is  necessary  in  doubtful  cases  for  the  exclusion  of  other  diseases. 
In  lobar  pneumonia  the  blood  during  the  first  few  days  shows  a  marked 
increase  of  leucocytes  which  may  run  to  40,000  per  cubic  millimeter.  The 
urine  is  scant  and  therefore  concentrated  and  contains  an  excess  of  uric 
acid.  Further,  a  febrile  albuminuria,  a  diazo-reaction,  and  a  decrease  or 
complete  absence  of  chlorides  are  observed.  The  sodium  chloride  is  prob- 
ably retained  in  the  lungs  and  the  pleura. 

Therapy. — In  uncomplicated  lobar  pneumonia  treatment  is  really  super- 
fluous. Good  nursing  is  the  only  requirement.  The  food  supply  should  be 
diminished  commensurately  with  the  loss  of  appetite,  but  the  patient  must 
be  given  plenty  to  drink  in  the  form  of  lemonade,  milk  with  mineral  water, 
etc.  The  fever  should  be  controlled  by  temperature  packs,  changed  at  half- 
hour  intervals  and  continued  for  a  few  hours  several  times  a  day,  or  by 
frequent  cool  sponging  or  tepid  baths.  If  the  fever  lasts  over  eight  days, 
antipyretics  may  be  given.  If  diarrhoea  occurs,  tannin  preparations  may  be 
used;  or  for  constipation,  castor  oil  or  glycerin  suppositories.  Indications 
of  cardiac  weakness,  especially  with  cold  extremities,  may  require  digitalis, 
caffein,  or  camphor.  (See  Cardiac  Insufficiency.)  After  crisis  the  temper- 
ature sometimes  falls  so  rapidly  that  it  may  be  necessary  to  use  hot  water 
bottles  or  other  warming  measures.  Expectorants  may  be  dispensed  with, 
but  they  are  harmless  in  small  quantities.  During  convalescence  suitable 
nourishment  must  be  provided.  (See  tuberculosis.) 

CHRONIC.  PNEUMONIA 

Chronic  infiltration  of  the  lung  tissue  sometimes  persists  after  broncho- 
pneumonia  complicating  influenza,  pertussis  or  measles.  It  usually  involves 
but  one  lobe,  but  this  often  to  a  considerable  extent.  In  such  cases  the  parie- 
tal and  visceral  pleura  are  apt  to  become  firmly  adherent,  although  leaving, 
sometimes,  small  fluid-containing  pockets.  The  affected  lung  retracts  and 
an  excessive  growth  of  interstitial  tissue  follows.  The  branches  of  the 
bronchi  running  through  the  disease  area  arc  often  enlarged  and  form 
cylindrical  bronchiectases. 

Upon  physical  examination,  extreme  dulness  with  a  tympanitic  note  and 
with  diminished  or  bronchial  breathing  is  discovered.  The  side  of  the 
thorax  involved  appears  smaller.  On  account  of  the  extreme  dulness  one 
may  be  led  to  suspect  pleurisy,  but  contrary  to  the  expectation  which  the 
latter  would  suggest,  exploratory  puncture  proves  negative.  The  infil- 
tration may  be  resorbed  after  several  months.  In  general,  the  prognosis 
is  good  if  the  condition  is  not  the  result  of  a  tuberculous  infection.  It  is  very 
important,  therefore  to  exclude  tuberculosis  which  may  be  done  by  means 
of  the  tuberculin  reaction.  There  is  no  special  therapy  aside  from  general 
measures,  good  dietary,  breathing  exercises,  and  fresh  air. 


382 


TEXT-BOOK  OF  PEDIATRICS 


EMPHYSEMA 

Acute  partial  emphysema  is  often  found  at  autopsy  in  fatal  cases  of 
broncho-pneumonia.  In  the  event  of  recovery  this  emphysema  disappears 
rapidly  and  has  no  clinical  significance.  True  emphysema,  due  to  over- 
expansion  of  all  the  pulmonary  alveoli,  develops  upon  rare  occasions  in  the 
wake  of  bronchial  asthma  and  pertussis.  Interstitial  subcutaneous  emphy- 
sema, in  which  the  air  is  forced  under  the  skin  through  the  mediastinum,  is 
occasionally  seen  after  wounds  of  the  lungs,  especially  after  tracheotomy 
and  sometimes  after  exploratory  puncture.  It  may  occur  spontaneously 
from  a  tuberculous  cavity,  or  from  the  rupture  of  alveoli  in  pertussis. 

BRONCHIECTASIS 

Aside  from  extremely  rare  cases  of  congenital  bronchiectasis,  dilatation 
of  the  bronchi  may  develop  as  a  result  of  subacute  pulmonary  disease  in 

children  of  over  three  years.  The  most  fre- 
quent of  these  is  whooping  cough,  then 
measles,  and  finally  pneumonia  from  other 
causes,  all  of  which  produce  a  distention  of 
the  bronchi  by  increasing,  the  intrathoracic 
pressure  during  the  attacks  of  coughing. 
Again,  bronchiectasis  may  arise  after  pleural 
diseases  in  which  in  consequence  of  retrac- 
tion, an  inspiratory  traction  acts  upon  the 
walls  of  the  bronchi. 

Pathologic  Anatomy. — Cylindrical  or 
sacculated  dilatation  of  the  bronchi  are 
found  usually  in  the  lower  lobe.  They  may 
be  single,  reaching  the  size  of  a  hen 's  egg, 
or  they  may  consist  of  multiple  pea-sized 
distensions.  The  mucous  membrane  be- 
comes atrophied  and  loses  its  ciliated 
epithelium,  the  secretion  stagnates  in  these 
cavities  and  presents  a  fertile  soil  for  the 
growth  of  various  micro-organisms. 

Clinically,  the  distressing  cough  persist- 
ing for  hours  is  characteristic.  It  occurs 
chiefly  in  the  mornings;  it  is  loose  and  ends 
with  the  expectoration  of  large  quantities 
of  sputum,  which  often  has  a  foul  odor.  This  expectorated  material  some- 
times shows  a  characteristic  division  into  three  layers.  Locally,  coarse  rales 
are  heard  in  a  limited  area  and  most  commonly  over  the  lower  posterior 
border.  Definite  signs  of  cavity  formation  are  rare.  It  is  an  important 
point,  that  before  the  paroxysm  of  coughing,  there  may  be  a  tympanitic 
note  or  a  slight  dulness,  which  disappears  after  the  expectoration.  If  the 
dilatation  is  near  the  surface,  a  cracked-pot  resonance  is  heard,  and  it  is 
possible  to  demonstrate  a  change  in  tone  when  the  mouth  is  opened  or  closed. 


FIG.  105. — Drumstick  fingers  in  case  of 
bronchiectasis,  ten-year-old  girl.  Watch 
glass  finger-nails. 


DISEASES  OF  THE  RESPIRATORY  ORGANS  383 

The  course  of  the  disease  is  extremely  chronic.  Slight  rises  of  temper- 
ature may  occur  for  a  long  time  without  any  general  symptoms  or  even 
anorexia.  The  fever  probably  varies  widely  with  the  type  of  micro- 
organism that  has  found  entrance  into  the  bronchiectasis.  The  condition 
is  almost  always  accompanied  by  local  bronchitis.  Pleuial  adhesions, 
misplacement  of  the  heart,  and  chronic  circulatory  disturbances  may  result, 
the  latter  leading  sometimes  to  the  formation  of  clubbed  fingers  (Fig.  105). 

Diagnosis  must  depend,  first  of  all,  upon  the  exclusion  of  tuberculous 
cavities,  and  this  may  be  done  by  means  of  the  tuberculin  reaction  and  by 
bacteriologic  examination  of  the  sputum. 

The  prognosis  of  large  bronchiectases  is  not  favorable.  Recovery  hardly 
ever  takes  place.  Death  usually  results,  sooner  or  later,  due  to  some 
complication. 

Therapeutically,  the  general  treatment  of  bronchitis  may  be  supple- 
mented by  massage  of  the  thorax,  breathing  exercises,  expiratory  compres- 
sion of  the  thorax,  and  inhalation  of  oil  of  pine  and  turpentine.  In  extreme 
cases,  surgical  interference  is  indicated. 

Resulting  pulmonary  abscess  and  gangrene  of  the  lung  with  thickening 
of  the  lung  tissue  and  a  gangrenous  odor  of  the  expired  air,  are  extremely 
rare  in  childhood. 

PLEURISY 

The  most  important  difference  between  the  pleural  exudations  of  child- 
hood and  those  of  later  life  consists  in  the  relative  frequency  of  pus.  Empy- 
emas  are  rare  during  the  first  half-year,  but  they  occur  quite  often  in  the 
second  half-year,  and  very  commonly  during  the  second  year,  after  which 
their  frequency  decreases  rapidly  from  year  to  year.  It  would  seem  that  the 
child's  pleura  is  especially  predisposed  to  infection  with  the  pneumococ- 
cus.  In  four-fifths  of  all  cases  of  pleurisy  in  childhood,  the  pneumococcus 
is  found  in  the  exudate,  while  it  is  present  in  only  one-fourth  of  the  adult 
cases.  This  explains  the  frequency  of  metapneumonic  empyema  after  lobar 
or  broncho-pneumonia.  As  pneumonia,  so  also  empyema  occurs  chiefly 
in  winter  and  spring.  Streptococcus  infections  of  the  pleura  are  less  com- 
mon in  children  than  among  adults,  excepting  in  the  new-born  in  whom 
they  appear  as  metastatic  localizations  of  a  general  sepsis.  Pleurisy  also 
occurs  in  cases  of  inflammation  of  neighboring  organs,  as  for  instance  in  ap- 
pendiceal  abscess.  It  may  be  associated  with  nephritis  and  sometimes  de- 
velops in  the  course  of  rheumatic  disease.  In  rheumatic  and  tuberculous 
cases,  a  serous  exudate  is  found.  Dry  pleurisies  are  relatively  uncommon 
in  childhood. 

In  the  septic  pleurisy  of  the  new-born,  the  disease  runs  concurrently 
with  a  general  sepsis  arising  from  the  umbilicus,  or  from  the  phlegmon  of 
the  thorax  or  the  mediastinum.  The  pus  in  the  pleural  cavity  contains 
streptococci.  It  may  be  demonstrated  by  the  dulness,  but  it  is  usually 
discovered  only  at  autopsy.  The  prognosis  of  this  form  of  the  disease  is  of 
course  bad.  Surgical  interference  is  hopeless. 

Fibrino-purulent  pleurisy  in  infancy  usually  represents  merely  a  second- 


384  TEXT-BOOK  OF  PEDIATRICS 

ary  finding  at  autopsy.  Around  the  infiltrated  lobes  in  pneumonia,  vil- 
lous  exudates  in  thick  masses  are  found.  By  careful  examination  this  form 
may  be  recognized  clinically,  in  some  instances,  by  the  friction  sound. 
Finkelstein  lays  great  stress  upon  the  presence  of  an  edema  over  the  area  of 
the  skin  of  the  thorax  beneath  which  the  exudate  lies.  This  edema  is  so 
slight  that  it  can  be  felt  only  upon  careful  examination. 

In  the  infant  a  pleurisy  may  arise,  without  pneumonia,  as  an  appar- 
ently primary  infection  of  the  pleural  cavity  or  from  a  lymphangitis  of  the 
mediastinum.  The  pleuritic  fibrinous  exudates  are  very  tough  and  show  no 
tendency  to  softening.  This  primary  lymphangitic  form  is  peculiar,  further- 
more, in  that  it  tends  to  spread  first  to  the  pericardium  and  then  to  the 
peritoneum  and  to  the  terminal  joints,  while  the  skin,  the  muscles,  and  the 
internal  organs  remain  free  of  metastases.  Heubner  has  described  it  as  a 
clinical  entity  under  the  term  multiple  purulent  serositis.  The  disease 
at  first  takes  a  course  resembling  pneumonia,  with  high  fever  and  indica- 
tions of  dyspnoea.  Distinct  pulmonary  symptoms,  however,  do  not  develop, 
but  collections  of  pus  in  the  pericardium  and  the  joints  become  manifest. 
Death  occurs  during  the  first  two  weeks. 

EMPYEMA 

In  most  cases  the  onset  of  the  disease  cannot  be  definitely  established. 
Especially  in  infants  the  collection  of  pus  usually  forms  during  the  pneu- 
monia and  the  symptoms  gradually  pass  from  one  to  the  other  type.  In 
other  cases,  signs  of  pleurisy  are  found  soon  after  a  high  febrile  onset,  but 
it  may  well  be  that  these  symptoms  have  been  merely  added  to  those  of  an 
ill-defined  pneumonia.  A  high  grade  dyspnoea  and  pains  which  are  referred 
again  to  the  stomach  region  are  characteristic  of  the  involvement  of  the 
pleura  if  it  develops  rapidly.  The  patient  prefers  to  He  upon  the  side  and 
especially  upon  the  affected  side,  because  it  permits  freer  breathing  with  the 
other  lung.  This  also  diminishes  the  respiratory  movements  of  the  affected 
side,  and  thereby  the  pain.  Inspection  reveals  fulness  of  the  affected  side 
The  thorax  is  fixed  and  does  not  participate  in  the  respiratory  movements. 
The  intercostal  spaces  bulge,  a  fact  which  can  be  determined  in  thin  children 
by  palpation.  Percussion  gives  absolute  dulness.  Care  must  be  taken  not 
to  percuss  too  hard  over  the  small  thorax  lest  the  tone  transmitted  from  the 
unaffected  lung  decrease  the  dulness.  The  phenomenon  which  Rauchfuss 
and  Hamburger  have  recently  described,  consisting  in  a  strip  of  resonance 
over  the  affected  lung,  depends  upon  the  fact  that  on  deep  percussion  the 
tone  of  the  one  side  is  transmitted  to  the  other  by  the  thoracic  wall.  Similar 
results  may  be  demonstrated  upon  the  anterior  surface  of  the  thorax. 
However,  the  seemingly  aberrant  note  over  the  border  of  the  dull  areas 
which  C9.n  be  made  out  upon  gentle  percussion,  does  not  depend  upon  these 
physical  causes,  but  rather  upon  changes  within  the  mediastinum  itself. 
For  if  the  exudate  is  on  the  left,  the  heart  is  pushed  to  the  right,  its  dulness 
extends  far  beyond  the  right  sternal  margin,  and  the  apex  beat  and  the 
heart  sounds  can  be  felt  and  heard  to  the  right  of  their  usual  areas,  while  in 


DISEASES  OF  THE  RESPIRATORY  ORGANS 


385 


right-sided  empyema  the  heart  is  not  only  forced  to  the  left,  but  the  liver 
is  pushed  downward.. 

Auscultation  does  not  present  the  definite  evidence  of  the  condition  in 
children  that  it  does  in  the  adult.  It  is  important  to  remember  that  the 
breath  sounds  are  not  inaudible,  but  may  be  almost  normal  or  even  of 
exaggerated  distinctness.  Usually  clear,  but  rather  distant  bronchial 
breathing  is  heard.  At  the  upper  border  of  the  dulness,  loud  bronchial 
sounds  and  regophony  are  heard.  When  the  exudate  recedes,  a  friction  rub 


FIG.  106 — Empyema  of  the  left  pleural  cavity,  distention  of 
the  left  side  of  the  thorax  with  loss  of  the  intercostal  spaces, 
heart  and  mediastina  pushed  to  right. 

or  fine  crackling  rales  become  audible.    The  filling  up  of  Traube's  space 
cannot  be  considered  a  symptom  in  childhood. 

The  course  of  empyema  depends  upon  the  extent  of  the  disease  process. 
Small  collections  of  pus  are  resorbed  and  leave  a  fibrinous  layer  upon  the 
pleura.  With  larger  collections  spontaneous  recovery  does  not  take  place. 
In  time  a  rupture  into  the  lung  may  occur,  with  expectoration  of  large 
quantities  of  pus  without,  however,  emptying  the  abscess  completely.  In 
other  cases  an  empyema  necessitatis,  with  rupture  through  the  thor- 
acic wall,  results.  Death  may  occur  at  any  stage  of  the  empyema  either 
from  insufficiency  of  the  lung,  cardiac  failure,  cachexia,  or  finally  from 
the  spread  of  the  infection  to  other  body  cavities  and  especially  to 
the  pericardium. 


386  TEXT-BOOK  OF  PEDIATRICS 

The  prognosis  of  empyema  depends,  to  a  certain  extent,  upon  the 
type  of  the  infecting  micro-organism.  Comparatively  speaking,  the  prog- 
nosis of  pneumococcus  empyema  is  favorable,  while  the  streptococcic  form 
may  cause  very  high  fever,  typhoidal  symptoms,  peritonitis  and  sepsis. 
In  the  latter  form  the  pleural  sac  refills  rapidly  after  removal  of  its  seropuru- 
lent  exudate.  Empyema  due  to  putrefactive  organisms,  such  as  may  appear 
after  gangrene  of  the  lung  or  typhoid  pneumonia,  is  not  very  acute  but  is 
very  obstinate.  In  this  type,  pyopneumothorax  may  be  produced  by  gas 
formation.  Tuberculous  empyema  may  also  lead  on  to  the  latter  form,  but 
this  is  a  comparatively  rare  occurrence-  and  its  prognosis  is  unfavorable. 

SEROFIBRINOUS  PLEURISY 

Serofibrinous  pleurisy,  like  empyema,  resulting  from  an  acute  infection, 
may  have  an  insidious  onset.  The  patient  does  not  recover  from  the  acute 
disease,  has  no  appetite,  becomes  emaciated,  and  develops  an  irregular 
fever.  Pain  is  felt  only  in  cases  of  rapid  onset  and  is  excited  by  coughing. 
The  signs  of  percussion  and  auscultation  as  well  as  misplacement  of  organs 
are  the  same  as  those  in  empyema.  Probably  a  larger  proportion  of  the 
serous  exudates  than  is  commonly  supposed  are  due  to  tuberculosis.  If  the 
tuberculin  reaction  is  positive,  this  etiology  is  always  the  more  probable, 
even  though  tubercle  bacilli  cannot  be  demonstrated  in  the  exudate  either 
microscopically  or  by  animal  inoculation. 

Rheumatic  affections  may  be  reckoned  as  second  in  importance  as  a 
cause  of  serous  pleurisy.  In  older  children  serous  exudates  .occur  in  asso- 
ciation with  acute  articular  rheumatirm  or  as  sequela)  of  angina.  In  these 
cases,  also,  the  exudates  are  free  from  bacteria.  They  are  often  bilateral. 
It  is  difficult,  sometimes,  to  determine  whether  these  are  really  transudates 
or  exudates.  They  do  not  as  a  rule  become  very  large. 

The  course  of  serous  pleurisy  is  much  more  benign  than  that  of  empy- 
ema. Death  results  but  rarely.  The  exudate  usually  disappears  after 
several  weeks  or  at  the  most  within  a  few  months;  nevertheless,  recovery  is 
hardly  ever  complete,  adhesions  and  thickening  of  the  pleura  usually  re- 
maining. These  are  found  for  the  most  part  posteriorly  and  over  the  lower 
lobes,  where,  by  an  area  of  slight  dulness  and  by  restricted  respiratory 
action,  it  is  possible  to  demonstrate  their  existence  for  years.  In  other 
instances,  retraction  may  ensue  which  draws  the  mediastinum  and  the 
heart  toward  the  affected  side  and  in  children  may  result  in  scoliosis  and 
serious  malformation  of  the  thorax. 

Diagnosis. — The  diagnosis  of  simple  fibrinous  pleurisy  may  be  made  by 
friction  sounds.  Relatively,  this  condition  is  of  little  importance.  It  is  of 
large  consequence,  however,  to  be  able  to  recognize  the  exudative  pleurisies, 
because  recovery  and  life  itself  may  depend  upon  proper  treatment.  The 
thorax  of  every  child  with  respiratory  disease  should  be  carefully  percussed. 
Every  marked  degree  of  dulness  should  awaken  the  suspicion  of  pleurisy 
first  of  all. 

If  increased  bronchial  breathing  and  crackling  rales  are  heard  over  the 
area  of  dulness,  it  is  safe  to  conclude  that  there  is  consolidation,  which  sug- 


DISEASES  OF  THE  RESPIRATORY  ORGANS  387 

gests  either  pneumonia  or  tuberculosis,  depending  on  the  course  of  the 
disease.  If  there  is  an  absence  of  bronchial  breathing,  the  suspicion  of 
pleurisy  is  strengthened.  Nevertheless,  emphasis  must  again  be  placed  upon 
the  fact  that  diminished  breath  sounds  are  not  invariably  found  over  an 
exudate.  Normal  or  even  bronchial  breathing  may  be  heard  over  the 
pleurisies  of  children.  The  most  important  questions  are:  Is  there  an 
exudate?  Is  it  serous  or  purulent?  Exploratory  puncture  should  be 
made  in  every  case  in  which  the  slightest  doubt  remains.  The  diagnosis 
cannot  always  be  made  from  the  physical  signs  alone,  and  frequent  sur- 
prises are  met  in  cases  in  which  infiltration  has  been  definitely  diagnosed, 


FIG.  107 — Exploratory  puncture  of  the  pleura. 

but  in  which  the  needle  brings  forth  fluid.  It  may  happen,  of  course,  that 
blood  is  aspirated  if  the  needle  is  passed  into  the  lung,  or  that  the  punc- 
ture gives  no  results  at  all  when  the  point  is  imbedded  in  a  thickened  pleura. 
In  case  of  only  a  small  circumscribed  area  of  dulness,  it  is  unnecessary 
to  explore,  because  little  depends  upon  the  result.  Small  pleuritic  exu- 
dates,  even  pus,  do  not  require  operation:  they  are  resorbed  spontaneously. 
Exploratory  puncture  is  best  done  below  the  scapula  at  a  point  where 
thoracotomy  may  be  performed  later  if  necessary.  Occasionally  it  may  be 
found  necessary  to  puncture  anteriorly,  then  care  must  be  taken  not  to 
injure  the  pericardium,  liver,  or  diaphragm.  It  is  best  to  mark  the  site  of 
the  intended  puncture,  determined  by  careful  percussion,  by  pressing  a 
finger  ring  firmly  against  the  skin  over  the  spot.  The  red  mark  of  the  ring 
remains  visible  for  several  minutes  and  cannot  be  washed  off.  No  anes- 


388  TEXT-BOOK  OF  PEDIATRICS 

thetic  is  required  for  the  operation.  The  wound  may  be  closed  by  means 
of  collodium  and  cotton,  or  with  adhesive  tape.  The  trocar  should  be  large 
enough  to  permit  the  passage  of  thick  purulent  fluid.  If  the  fluid  is  of  a 
serous  nature,  no  operative  procedure  is  required,  unless  the  exudate  is  on 
the  left  side  and  causes  marked  signs  of  compression  of  the  heart.  In  this 
event  a  larger  needle  may  be  passed  at  the  same  point  and  the  fluid  drawn 
out  with  a  syringe  or  a  Dieulafoy  aspirator. 

If  the  exploratory  puncture  reveals  purulent  fluid,  steps  must  be  taken 
to  remove  the  exudate  as  completely  as  possible.  The  most,  satisfactory 
measure  for  this  purpose  is  thoracotomy  with  partial  resection  of  the  ribs. 
Puncture  in  the  intercostal  space  with  drainage  is  loss  satisfactory,  since 
the  drain  may  be  compressed  by  the  ribs  which  will  obstruct  the  flow. 

Irrigation  of  the  cavity  has  little  value;  in  fact,  it  seems  to  retard  healing 
in  some  cases.  Partial  resection  of  the  ribs  is  carried  out  under  anesthesia. 
A  longitudinal  incision  is  made  over  the  rib  immediately  above  the  puncture. 
The  periosteum  is  pushed  aside  and  a  semicircular  piece  is  taken  out  of  the 
rib  with  rongeur  forceps  having  curved  jaws.  A  fine  forceps  carrying  a 
suitable  drain  is  then  forced  through  the  periosteum  and  the  pleura  into  the 
cavity.  The  drain  is  fastened  in  place  in  the  usual  manner  and  closed  at  its 
outer  end.  If  the  skin  incision  is  small,  it  is  sometimes  possible  to  make  all 
the  pus  flow  out  through  the  drain,  which  is  opened  for  the  purpose  once 
or  twice  a  day.  Usually  pus  flows  along  the  outside  of  the  drain  into  the 
dressings,  necessitating  frequent  change. 

Even  after  thoracotomy,  the  prognosis  of  empyema  is  not  very  good. 
About  twenty  per  cent,  of  the  cases  die  and  during  the  first  year  of  life  this 
percentage  is  even  higher.  Nevertheless,  the  prognosis  is  better  with  than 
without  operation,  so  that  failure  to  perform  thoracic  puncture  and  to 
withdraw  the  pus  must  be  considered  an  error  in  treatment. 

TREATMENT  OF  SEROUS  PLEURISY 

In  mild  cases  of  serous  pleurisy  the  treatment,  should  be  expectant. 

The  salicylates,  digitalis  (0.1-0.3  gm.),  theobromine  sodio-salicylate 
(2.0-5.0  gms.)  for  a  period  of  two  days,  together  with  the  local  use  of  iodin 
ointment  or  the  inunction  of  volatile  oils,  may  be  given.  Codein  may  be 
used  to  quiet  the  cough.  During  the  acute  stage,  moist  applications,  either 
hot  or  cold,  as  may  be  the  better  borne,  may  be  used.  The  exudate  is 
removed  only  when  the  signs  of  cardiac  compression  become  marked. 
(See  Fig.  106.) 

Orthopedic  procedures  must  be  instituted  early  to  overcome  the  defor- 
mity of  the  thorax.  Creeping,  gymnastics,  swimming,  etc.,  are  advised, 
with  general  good  hygiene. 


V. 
DISEASES  OF  THE  HEART 

BY 

E.  PEER, 

Zurich. 

REVISED  AND  EDITED  BY 

HENRIETTA  ANNE  CALHOUN,  M.  A.,  M.  D., 

State  University  of  Iowa. 

DISTURBANCES  of  cardiac  rhythm  are  common  in  childhood.  Tachy- 
cardia, more  or  less  physiologic  in  young  children,  may  reach  a  high  degree 
in  neuropathic  patients,  and  is  readily  and  temporarily  caused  by  fever, 
excitement,  etc.  Even  in  older  children  of  nervous  temperament  excite- 
ment or  exertion  may  cause  a  marked  increase  in  the  pulse-rate.  The 
apex  beat  may  be  more  diffused  while  the  pulse  may  become  small  and 
compressible  without  indicating  by  this  transient  disturbance,  cardiac 
weakness  or  dilation.  For  the  purposes  of  observation,  mild  exercise  may 
be  standardized  as  follows:  (a)  running  up  two  flights  of  stairs  twice; 

(b)  slowly  raising  the  body  from  a  horizontal  to  a  sitting  posture  ten  times ; 

(c)  ten  complete  flexions  of  the  knees  while  standing.    If  the  pulse-rate 
which  has  been  increased  as  a  result  of  such  mild  exercise  does  not  re- 
turn to  normal  within  three  minutes,  it  is  safe  to  conclude  that  there  is  a 
heart  lesion. 

The  electrocardiograph  may  be  used  to  differentiate  benign  from  serious  cases. 
The  heart-beat  originates  in  the  upper  part  of  the  sino-auricular  node  and  spreads  in  all 
directions  over  the  auricle  at  a  rate  of  about  1000  mm.  per  second.  The  left  auricle 
contracts  0.013  second  later  than  the  right,  and  the  ventricular  contraction  is  0.2  sec- 
ond later,  the  wave  passing  through  the  ventricle  at  a  rate  of  400  mm.  per  second.  In 
the  Purkinje  fibres  the  rate  is  2000  mm.  per  second.  The  contraction  wave  passes  from 
the  right  auricle  to  the  left  auricle,  through  the  auriculoventricular  bundle  to  the  ven- 
tricle. The  interval  between  the  right  auricular  and  the  ventricular  contraction  is  the 
P-R  time  on  the  graph.  Each  contraction  calls  forth  the  full  response  of  the  heart  muscle 
cells,  and  is  followed  by  a  period  of  rest.  At  the  beginning  of  systole  there  is  a  short 
refractory  period  during  which  outside  stimuli  have  no  effect.  The  R  wave  on  the  graph 
is  the  ventricular  contraction  or  the  apex  beat  or  the  radial  pulse  time.  At  72  beats 
per  second  the  interval  between  the  R  wave  is  0.6  second.  Irregularities  due  to  auric- 
ular and  sinus  variations  in  time  are  benign,  while  disturbances  of  the  ventricular  rate 
and  rhythm,  dissociation  of  auricle  and  ventricle,  and  auricular  fibrillation  are  of  seri- 
ous import. 

The  electrocardiogram  in  a  child  shows  some  important  variations  from  the  adult 
type.  In  infants  it  is  smaller,  the  S  wave  is  unusually  prominent  gradually  becoming 
smaller  and  reaching  the  adult  type  from  the  second  to  the  twelfth  month  of  extra- 
uterine  life.  The  Q  wave  is  more  frequently  present  in  the  new-born,  and  the  P-R  inter- 
val varies  from  0.10  second  in  nurslings;  0.13  in  early  childhood;  0.14  at  puberty;  to 
0.12-0.17  second  in  adults. 

Paroxysmal  tachycardia  has  been  observed  in  older  children.  In  sev- 
eral instances  it  has  been  hereditary.  Complete  recovery  is  possible. 

389 


390  TEXT-BOOK  OF  PEDIATRICS 

Paroxysmal  tachycardia  of  auricular  origin  and  auricular  flutter  are  very  similar,  both 
showing  rapid  coordinated  auricular  systoles,  the  contractions  arising  outside  of  the  sino- 
auricular  node.  Both  are  reported  in  children  but  differentiation  of  the  two  is  difficult 
because  in  children  the  auricle  may  exceed  200  beats  per  minute  without  any  heart- 
block  being  present.  The  auricular  rate  in  paroxysmal  tachycardia  is  seldom  more  than 
200-250  per  minute,  although  500  per  minute  have  been  counted  on  a  polygraph  record. 
(Hume.)  Auricular  fibrillation  is  a  rare  but  very  grave  condition  in  childhood  which  is 
most  frequently  associated  with  cardiac  decompensation  and  a  history  of  rheumatic  fever. 

According  to  Hochsinger,  compression  cf  the  vagus  by  enlarged  bron- 
chial lymph  glands  may  result  in  permanent  tachycardia. 

Arhythmia  is  occasionally  physiologic  in  young  children,  and  may  be 
demonstrated  during  sleep. 

This  is  usually  a  type  of  respiratory  arhythmia  which  becomes  more  marked  from 
birth  to  puberty;  children  whose  normal  heart  rate  is  rapid  showing  the  more  marked 
variation. 

AVERAGE  DIFFERENCE  IN  TIME  BETWEEN  THE  LONGEST  AND  SHORTEST  PULSE  PERIODS 
AT  VARYING  AGES  MEASURES  IN  Jv  OF  A  SECOND.     (Hecht.) 

Age.  Time  Interval. 

Premature  infants 2.5 

New-born  infants 3.4 

Nurslings 2.8 

Young  children   6.25 

Older  children 8.4 

In  convalescence  from  infectious  diseases,  especially  pneumonia  and 
typhoid  fever,  arhythmia  frequently  continues  for  days  or  weeks.  Usually 
this  is  not  of  much  importance;  but  in  diphtheria  it  is  serious.1  It  fre- 
quently appears  in  the  acute  and  chronic  disturbances  of  infancy,  espe- 
cially in  decomposition.  Tuberculous  meningitis  at  its  onset,  is  frequently 
a  cause  of  arhythmia.  In  older  children  it  is  often  impossible  to  find  any 
cause  other  than  nervousness.  When  the  pulse-rate  is  increased  as  a 
result  of  fever  or  exertion  the  arhythmia  disappears.  It  is  a  frequent  and 
quite  harmless  symptom  which  is  by  no  means  always  attributable  to 
myocarditis.  It  is  usually  dependent  upon  a  lengthening  of  the  diastole. 
Extra  systole  (Hirsch)  often  occurs  with  organic  injury  of  the  heart  as  in 
diphtheria,  etc. 

In  children  premature  beats  arising  in  the  auricles  are  more  common  than  those 
arising  from  ventricles,  which  is  the  reverse  of  the  findings  in  adults.  Extra  systoles 
are  more  serious  when  they  occur  before  ten  years  of  age  associated  with  other  signs  of 
cardiac  disease. 

The  cardiac  diseases  of  childhood  cause  arhthymia  much  less  fre- 
quently than  do  those  of  adults,  because  chronic  myocarditis  is  far  less 
common  in  youth  and  because  a  severe  degree  of  arteriosclerosis  is  prac- 
tically unknown.  Arhythmia  is  present  occasionally  in  endocarditis  and 
with  the  ordinary  valvular  lesions.  Bradycardia  is  often  associated  with 
arhythmia.  It  is  characterized  by  ineffective  contractions  which  do  not 
give  a  palpable  pulse-wave,  and  is  found  in  the  same  diseases  as  arhyth- 

1  Not  infrequently  this  arhythmia  in  diphtheria  is  an  atrioventricular  rhythm  recog- 
nized by  a  reduction  in  the  a-c  interval  in  the  polygraph.    (Wilson.) 


DISEASES  OF  THE  HEART  391 

mia,  and  especially  with  an  infectious  myocarditis  incident  to  either  diph- 
theria or  scarlet  fever.  Occasionally  bradycardia  occurs  during  a  recovery 
from  appendicitis.  In  infancy  slowing  of  the  pulse  is  less  common  than 
in  later  years,  and  is  often  absent  even  inicterus  and  tuberculous  meningitis. 
The  author  has  seen  in  a  four  months'  old  infant  a  pulse-rate  of  sixty 
to  seventy,  uninfluenced  even  by  a  temperature  of  40°  C.  (104°F.).  This 
condition  was  supposedly  due  to  a  myopericarditis.  The  case  terminated 
in  sudden  death.  In  such  cases  heart-block  must  be  taken  into  consideration. 

So  far  only  auriculoventricular  and  sino-auricular  block  have  been  reported  in  child- 
hood. Most  cases  are  due  to  acute  inflammatory  conditions,  especially  to  acute  rheu- 
matic fever  and  diphtheria.  Pneumonia,  influenza  and  other  infectious  diseases  are  less 
frequent  factors.  Heart-block  in  acute  infectious  diseases  may  occur  without  any 
demonstrable  structural  changes  in  the  auricular  ventricular  bundle.  Congenital  mal- 
formations may  also  be  associated  with  heart-block,  but  septal  defects  do  not  involve 
the  a-v  bundle.  Digitalis  in  large  doses  may  cause  heart-block.  Syphilis  infrequently 
or  never  produces  heart-block  in  children.  (Wilson.) 

In  the  electrocardiogram  the  distance  between  the  P  wave  (auricular  systole)  and  the 
QRS  group  (ventricular  systole)  is  lengthened  with  an  increase  in  the  a-c  interval  in  the 
phlebogram,  in  heart-block. 

HEART  MURMURS 

There  are  many  cardiac  conditions  that  involve  changes  in  the  heart 
sounds,  as  determined  by  auscultation,  in  which  percussion  findings  are 
not  necessarily  changed.  In  infancy,  the  first  sound  of  the  heart  is  often 
dulled  and  even  impure.  The  loud  sounds  characteristic  of  childhood 
are  noted  only  at  a  later  age. 

Heart  murmurs  are  extremely  frequent.  During  the  first  two  or  three 
years  they  commonly  indicate  congenital  lesions,  because  acquired  changes 
are  quite  rare  at  this  age  and  accidental  murmurs  are  heard  in  exceptional 
cases  alone. 

The  murmurs  which  arise  in  so-called  functional  insufficiency,  as  the 
mitral  and  tricuspid  murmurs  in  uncompensatcd  heart  lesions,  or  those 
which  follow  the  nephritis  of  scarlet  fever,  due  to  dilatation,  are  closely 
related  to  the  murmurs  of  true  valvular  disease. 

All  other  murmurs  may  be  classified  as  accidental.  These  are  more 
common  at  school  age  than  during  any  other  period,  and  they  greatly 
exceed  in  frequency  the  murmurs  due  to  organic  valvular  lesions.  Accord- 
ing to  some  authors  these  murmurs  are  found  in  fifty  per  cent,  of  all  school 
children.  Liithje  found  slight  systolic  murmurs  in  three-fourths  of  chil- 
dren of  school  age.  He  attributes  them  to  a  relatively  large  pulmonary 
artery  with  a  small  ostium. 

According  to  Hochsinger,  accidental  heart  murmurs  hardly  ever  occur 
during  the  first  three  years.  But,  in  common  with  Thiemich,  v.  Starck, 
and  others,  the  writer  has  often  been  able  to  demonstrate  distinct  mur- 
murs in  children  of  one  or  two  years  of  age,  in  whom  autopsy  showed  no 
structural  cause  and  this,  too,  in  cases  in  which  the  discovery  of  the  mur- 
mur antedated  the  period  immediately  preceding  death.  It  cannot  be 
denied,  however,  that  accidental  sounds  are  comparatively  rare  during 
the  first  three  or  four  years. 


392  TEXT-BOOK  OF  PEDIATRICS 

Accidental  murmurs  are  characterized  by  their  systolic  synchrony, 
by  their  soft,  sighing  quality,  and  by  their  optimum  recognition  at  the 
left  border  of  the  heart,  that  is  in  the  region  of  the  pulmonary,  and  only 
occasionally  in  the  area  of  the  mitral.  The  cardiac  dulness  is  normal, 
the  pulmonic  second  sound  is  not  accentuated.  The  cause  of  these  accidental 
murmurs  has  not  been  determined.  Many  authorities,  among  them 
Hochsinger,  Potain,  Herman  Mueller  and  recently  Schlieps,  with  whom 
the  writer  agrees,  suppose  that  most  of  these  sounds  are  cardiopulmonic 
— 'that  is,  that  they  are  caused  by  the  changes  which  the  lingula  of  the 
lung  undergoes  during  systole.  The  explanations,  however,  of  the 
phenomenon  differ  essentially.  The  fact  that  these  sounds  are  not 
at  all  constant  speaks  for  their  extracardiac  and  pulmonic  origin. 
Furthermore,  that  they  appear  or  actually  become  more  distinct  during 
excitement,  in  rapid  breathing,  or  when  deep  inspirations  are  taken,  and 
that  they  disappear  upon  forced  expiration,  or  when  the  breath  is  held  in 
expiration,  or  upon  changes  of  position,  are  equally  suggestive  facts. 
They  are  heard  more  frequently  when  the  patient  is  standing  than  when 
he  is  lying  down.  The  systolic  sound  is  never  completely  obscured  by 
the  murmur  which  begins  in  the  middle  phase  of  the  systole. 

A  minor  number  of  accidental  murmurs  seem  to  be  due  to  a  transient 
insufficiency  of  the  valvular  papillary  muscles  of  the  mitral,  without  lesion 
of  the  valve  itself  and  without  cardiac  dilatation,  as  in  the  group  of  rela- 
tive insufficiencies.  Many  of  the  murmurs  occuring  in  the  febrile  dis- 
eases such  as  those  of  acute  myocarditis  come  under  this  head.  The  sounds 
temporarily  disappear  with  an  increase  of  nervous  excitation  or  of  muscu- 
lar force.  Schlieps  calls  these  murmurs,  to  the  existence  of  which  the 
writer  has  called  attention  in  earlier  editions,  atonic  heart  murmurs. 
They  occur  principally  in  large,  flaccid,  neuropathic  girls  and  in  cachectic 
convalescents  from  typhoid  and  scarlet  fever.  With  this  type  the  sys- 
tolic sound  is  entirely  lost.  The  murmur  often  disappears  when  the  adom- 
inal  aorta  or  the  femoral  artery  is  compressed  (Schlieps). 

In  still  other  cases,  accidental  murmurs  may  be  dependent  upon  an 
increased  rate  of  flow  or  upon  a  diminished  density  of  the  blood.  Sahli 
maintains  that  these  causes  frequently  obtain  in  adults.  Murmurs  which 
occur  in  fever  under  increased  cardiac  activity,  in  the  anemias-  of  late  child- 
hood, and  particularly  in  those  cases  in  which  a  venous  hum  may  be  de- 
tected, probably  belong  in  this  group. 

From  this  discussion  the  reader  will  recognize  the  difficulty  of  deter- 
mining the  cause  of  a  systolic  murmur  in  certain  cases;  especially  since  in 
the  mitral  insufficiencies  of  childhood  the  accentuation  of  the  pulmonic 
second  sound  and  the  dilatation  of  the  right  heart  may  not  appear  for  a 
long  period. 

In  the  differentiation  of  questionable  cases  these  especially  distinctive 
points  may  be  applied,  but  they  do  not  always  enable  us  to  reach  a  definite 
conclusion.  Persistent  observation  gives  one  the  best  results  and  proves 
how  frequently  in  older  children  the  diagnosis  of  organic  valvular  lesions 
is  made  upon  insufficient  data. 


DISEASES  OF  THE  HEART  393 

A  split  pulmonic  second  sound  is  often  heard  in  healthy  children  when 
they  are  under  the  influence  of  excitement,  or  when  they  are  crying  or 
straining,  the  congestion  of  the  lung  causing  an  earlier  closure  of  the  pul- 
monary than  of  the  aortic  semilunar  valve.  Accentuation  of  the  pulmonic 
second  sound  may  be  observed  under  the  same  circumstances,  but  has 
no  significance. 

Venous  murmurs  are  often  heard  in  older  children.  Apart  from  the 
venous  hum  which  may  often  be  heard  in  anemic  patients  upon  ausculta- 
tion, with  careful  avoidance  of  pressure,  over  the  veins  in  the  neck,  there 
are  weak,  long-drawn  out  or  even  continuous  murmurs,  traceable  to  the 
large  veins,  which  can  be  heard  oftentimes  on  both  sides  of  the  sternum. 
On  the  right  of  the  sternum  alone,  a  particularly  loud  murmur,  with  its 
maximal  audibility  below  the  aortic  area,  may  be  discovered.  This  mur- 
mur again  is  long-drawn  out,  almost  continuous,  often  of  very  striking 
quality,  and  loudest  in  systole.  It  is  possible  that  this  sound,  which  is 
variable  and  most  commonly  heard  in  anemic  patients,  arises  in  the  supe- 
rior vena  cava.  Resembling  this  sound,  demonstrated  over  the  sternum,  is 
a  note  which  in  tuberculous  patients  is  produced  by  the  pressure  of  enlarged 
bronchial  glands.  In  the  tuberculous  and  the  non-tuberculous  alike,  such 
an  intrathoracic  note  may  be  developed  by  bending  the  head  backwards 
as  far  as  possible.  (Eustace  Smith.) 

When  the  diagnosis  of  an  organic  heart  lesion  has  been  made,  there 
remains  the  difficulty  of  deciding  whether  the  injury  is  congenital  or  ac- 
quired. In  addition  to  the  facts  already  recited  the  following  points  bear 
upon  this  differential  question.  A  loud,  rough,  musical  murmur,  with  nor- 
mal area  of  dulness;  or  a  murmur  present  in  infancy,  with  enlarged  area 
of  dulness  and  a  weak  apex  beat  (Hochsinger) ;  or  a  murmur,  absent  at 
the  apex,  but  prominent  in  the  pulmonary  region — indicates,  in  general, 
a  congenital  lesion.  A  very  loud  murmur,  distinctly  audible  over  the  entire 
heart,  but  without  purring  quality,  lends  probability  to  the  diagnosis  of  an 
open  septum.  A  purring  systolic  murmur,  with  its  maximal  intensity  at 
the  upper  third  of  the  sternum,  unassociated  with  distinct  cardiac  hyper- 
trophy, is  indicative  of  an  open  ductus  arteriosus  (Botalli). 

A  large  number  of  causes  of  disease  which  play  an  important  r61e  in 
the  adult  are  rarely  present  or  entirely  lacking  in  the  child.  Thus  arterio- 
sclerosis, which  in  the  adult  often  leads  to  lesions  of  the  aortic  valves  and 
even  to  aneurism,  never  develops  in  early  life;  nor  are  its  consequences, 
by  way  of  chronic  myocarditis  and  angina  pectoris,  ever  seen  at  this  period. 
Injuries  to  the  heart  from  the  excessive  use  of  alcohol  and  tobacco,  or  inci- 
dent to  obesity,  are  extremely  rare  in  childhood. 

NERVOUS  DISTURBANCES 

Primary  nervous  disturbances  of  the  heart  are  very  much  less  common 
than  in  the  adult.  Cardio-neuroses,  due  to  thyreotoxic  causes  (Basedow's 
Disease),  occur  only  occasionally  in  late  childhood.  Children  hardly  ever 
complain  of  palpitation  before  the  sixth  to  the  eighth  year,  even  when 


394  TEXT-BOOK  OF  PEDIATRICS 

heart  action  is  very  much  increased.  Occasionally,  long-continued  mastur- 
bation may  lead  to  palpitation  and  increased  rapidity  of  the  pulse. 

Spasmophilia  is  a  frequent  cause  of  sudden  death  in  young  children; 
and  death  in  laryngospasm  is  caused  by  sudden  stoppage  of  the  heart  and, 
according  to  Ibrahim,  by  tetany  of  the  heart  and  not  by  asphyxia.  The 
diminished  resistance  of  the  heart  in  cases  of  exudative  diathesis  is  dis- 
cussed under  the  head  of  infectious  diseases.  The  etiology  of  sudden  deaths 
in  this  condition,  which  may  occur  even  "without  infection,  is  not  well  under- 
stood. Since  the  heart  muscle  is  often  entirely  normal,  it  appears  to  be 
rather  a  question  of  failure  of  the  nervous  mechanism.  The  greater  insta- 
bility of  the  heart  in  these  cases  must  be  caused  by  the  general  diathesis. 

The  cardiac  disturbances  of  neuropathic  children  have  been  little  stu- 
died. They  are  generally  characterized  by  great  instability  of  the  pulse- 
rate.  Severe  pain  and  sudden  fright  may  cause  a  slow  and  irregular  pulse. 
Sudden  death  has  occurred  from  these  causes, 

CONGENITAL  HEART  LESIONS 

The  relative  frequency  of  congenital  heart  lesions  challenges  great  inter- 
est, for  the  relative  frequency  remains  even  after  the  exclusion  of  disturb- 
ances so  severe  as  to  cause  death  within  a  short  time  after  birth. 

Anomalies  of  growth  are  the  causative  influence  of  a  large  proportion 
of  these  cases,  a  relationship  occasionally  shown  by  other  coexisting  mal- 
formations (hare-lip,  cleft  palate,  etc.).  Congenital  heart  lesions  are  found 
too  commonly  in  myxedema  and  mongolism  to  be  regarded  as  a  matter  of 
mere  chance.  Intra-uterine  infection  of  the  heart  and  the  great  vessels  is 
a  more  frequent  cause  of  congenital  lesions  than  has  been  hitherto  believed. 
It  is  very  often  impossible  to  differentiate  between  these  two  causative 
factors  even  at  autopsy,  since  inflammatory  conditions  are  easily  added  to 
prenatal  malformations. 

Many  congenital  heart  lesions  are  associated  with  irregularities  or  per- 
versions of  the  normal  heart  growth,  into  the  discussion  of  which  we  can- 
not enter.  The  customary  division  of  the  primary  simple  cylindrical  tube, 
the  truncus  arteriosus  of  the  early  embryonic  heart,  into  the  aorta  and  the 
pulmonary  artery,  the  subsequent  development  of  the  left  ventricle  and 
of  the  interventricular  septum,  is  so  complicated  a  process  that  it  is  fre- 
quently disturbed  and  gives  rise  to  most  of  the  abnormalities  of  develop- 
ment. Atresia  or  stenosis  of  one  or  the  other  of  these  channels,  or  even 
transpositions  of  them,  occur,  in  consequence  of  the  early  abnormal  rela- 
tion of  the  aorta  to  the  pulmonary  artery.  Very  often  various  anomalies 
appear  in  combination  and  others,  such  as  the  non-closure  of  the  ductus 
arteriosus,  are  merely  compensatory. 

These  several  combinations  make  the  diagnosis  of  the  individual  case 
much  more  difficult  than  the  recognition  of  acquired  lesions.  Many  phy- 
sicians never  attempt  a  diagnosis,  but  are  content  with  the  application  of 
the  term  "morbus  cceruleus." 

Cyanosis  is,  of  course,  a  very  frequent  and  prominent  symptom  of  con- 
genital heart  lesions  and  is  often  noticeable  immediately  after  birth.  It  is 


DISEASES  OF  THE  HEART  395 

of  some  prognostic  value,  since,  generally  speaking,  infants  who  show  severe 
cyanosis  from  birth  rarely  live  very  long.  Children  who  are  only  slightly 
cyanotic,  or  those  that  do  not  become  cyanotic  until  their  first  or  second 
year,  have  a  much  more  favorable  prognosis.  The  cause  of  the  cyanosis 
is  not  quite  clear.  Certainly  pulmonary  congestion  does  not  always  occur, 
as  evidenced  by  the  fact  that  there  is  no  edema.  Nor  does  the  relative 
thickness  of  the  walls  of  the  veins  readily  permit  their  distension.  Fre- 
quently an  admixture  of  venous  with  arterial  blood  is  a  factor  in  its  causa- 
tion. Finally,  hyperglobulia,  a  later  accompaniment  of  congenital  heart 
lesions,  runs  parallel  in  a  measure  to  the  cyanosis  (6-8  millions).  This 
condition,  with  its  significant  increase  of  the  hemoglobin  and  its  enlarge- 
ment of  the  erythrocytes,  is  in  the  nature  of  a  compensatory  arrangement, 
whereby  the  strained  oxygen  supply  of  the  organism  is  reinforced. 

There  is  an  intimate  relationship  between  the  degree  of  cyanosis  and  the  oxygen 
unsaturation of  the  blood;  (i.  e.,  the  difference  between  oxygen  capacity  and  oxygen  con- 
tent per  100  c. c.  of  blood).  With  an  oxygen  unsaturation  below  8  volumes  per  cent., 
there  is  no  cyanosis;  with  8-13  volumes  per  cent,  there  may  or  may  not  be  cyanosis, 
while  with  an  unsaturation  of  more  than  13  volumes  per  cent,  there  is  always  cy- 
anosis. When  the  hemoglobin  falls  below  35'per  cent,  cyanosis  is  not  found.  In  hyper- 
globulia compensating  for  the  deficient  oxygen  unsaturation,  the  color  is  reddish,  an 
erythrosis  which  should  be  sharply  differentiated  from  the  bluish  color  of  a  true 
cyanosis.  (Lundsgaard.) 

In  some  cases,  even  at  birth,  the  cyanosis  is  so  distinct,  affecting  the 
entire  body — the  skin  and  mucous  membranes — that  it  is  observed  by  the 
laity.  In  other  instances  only  the  lips,  the  ears,  the  finger-tips  and  the 
toes  are  slightly  blue,  so  that  the  condition  may  not  be  noticed  in  a  hurried 
examination.  In  time,  the  drumstick  fingers  (see  Fig.  105),  develop  some- 
times in  a  very  marked  degree.  Then,  too,  there  are  cases  in  which,  while 
the  patient  is  at  rest,  no  sign  of  cyanosis  can  be  recognized;  but  in  which 
it  appears  distinctly  when  the  patient  cries,  or  strains,  or  holds  his  breath. 
In  this  connection  it  must  be  observed  that  even  healthy  new-born  babes 
may  become  cyanotic  when  they  cry  very  hard.  Finally,  there  are  cases 
in  which  cyanosis  makes  its  appearance  only  after  months  or  even  years. 

Moreover,  it  must  be  remembered  that  there  are  many  congenital  heart 
lesions  \\hich  never  show  any  degree  of  cyanosis,  so  that  it  is  quite  inap- 
propriate to  apply  to  them  the  term  morbus  cceruleus. 

At  the  outset  the  symptoms  are  not  always  distinct.  Cardiac  changes 
to  be  determined  by  auscultation  may  be  absent  or  easily  overlooked  at 
this  early  period.  Generally  speaking,  heart  murmurs  give  the  most  im- 
portant indications.  Acquired  lesions  or  functional  murmurs  are  very 
uncommon  during  the  first  three  years  of  life,  so  that  the  demonstration 
of  a  murmur  in  infancy  may  be  said  to  predicate  a  congenital  lesion.  If 
the  murmur  is  unusually  loud,  the  diagnosis  may  be  established  upon  this 
evidence  alone  (see  below).  In  most  cyanotic  cases,  however,  percussion 
reveals  an  enlarged  area  of  cardiac  dulness.  Its  extension  is  most  marked 
in  the  right  field  because  the  majority  of  these  lesions  involve  the  right  side 
of  the  heart  and  are  in  the  nature  of  pulmonic  stenoses.  Other  defects, 
and  particularly  those  of  the  septum,  occur  without  evident  enlargement. 


396  TEXT-BOOK  OF  PEDIATRICS 

Respiration  is  always  increased  in  frequency  and  sometimes  to  the  ex- 
tent of  dyspnoea.  Catarrhal  symptoms,  due  to  vascular  congestion,  are 
common  and  are  often  the  precursors  of  broncho-pneumonia — the  most 
common  cause  of  death  in  infants  with  congenital  heart  lesions. 

Edema  is  comparatively  rare  and  occurs  late  if  at  all,  a  fact  explained 
by  the  thickness  and  hence  the  resistance  of  the  vessel  walls.  There  is  far 
less  tendency  in  the  organism  of  the  young,  than  in  the  adult,  to  respond 
to  cardiac  insufficiency  by  the  development  of  edema — a  peculiarity  noted, 
also,  in  the  acquired  heart  lesions  of  young  children. 

A  common  coincident  of  congenital  heart  lesions  is  a  general  hypopla- 
sia,  a  retardation  of  physical  and  mental  development.  The  condition  may 
be  readily  understood.  Such  results  of  severe  lesions  may  be  seen  even  in 
childhood.  In  the  absence  of  any  disturbance  of  nutrition,  the  failure  of 
normal  development  in  itself  often  leads  the  physician  to  suspect  a  congen- 
ital heart  lesion,  a  suspicion  often  confirmed  later,  when  no  heart  symptoms 
are  immediately  apparent.  The  tendency  to  subnormal  temperatures  and 
cold  extremities,  common  in  children  with  congenital  heart  lesions,  is 
explained  by  the  insufficient  decarbonization  of  the  blood.  Such  patients 
are  often  inclined  to  be  peevish  and  irritable. 

The  prognosis  of  congenital  cardiac  lesions  is  extremely  variable.  Some 
cases  are  inevitably  fatal  immediately  after  birth,  or  within  a  few  days; 
while  others  are  met  with  which  do  not  affect  the  general  health  at  all. 
Death  is  usually  due  either  to  cardiac  insufficiency,  to  intercurrent  infec- 
tious disease,  or  to  broncho-pneumonia.  Tuberculosis  is  a  generally  recog- 
nized cause  of  death  in  pulmonic  stenosis. 

Treatment  consists  in  prophylaxis  against  dangerous  complicating 
diseases,  rather  than  in  active  measures  against  the  heart  lesion  itself.  The 
best  possible  care,  warm  clothing,  avoidance  of  exposure  to  cold,  and  plenty 
of  fresh  air,  are  the  essentials  to  be  secured.  Especial  care  should  be  taken 
to  avoid  the  contagion  of  measles  and  pertussis.  If  cardiac  insufficiency 
and  increasing  cyanosis  are  threatening,  the  usual  heart  remedies,  and  es- 
pecially digitalis,  together  with  inhalations  of  oxygen,  are  indicated.  The 
effect  of  these  remedies  is  usually  temporary.  Their  use  should  be  delayed 
as  long  as  possible  in  order  not  to  whip  the  heart  unnecessarily. 

1.  DEFECT  OF  THE  INTERVENTRICULAR  SEPTUM 
ROGER'S  DISEASE 

Defect  of  the  wall  between  the  ventricles  is  of  common  occurrence.  It 
is  always  due  to  developmental  error  and  for  this  reason  other  structural 
anomalies,  such  as  hare-lip,  etc.,  are  frequently  associated  with  it. 

The  defect  is  nearly  always  situated  in  the  upper  membranous  portion 
of  the  septum.  If  it  is  extensive  it  produces  no  audible  murmur.  In  most 
instances,  however,  the  all  important  symptom  is  a  very  loud,  rough,  sys- 
tolic murmur,  audible  over  the  entire  cardiac  area,  with  its  maximal  inten- 
sity on  the  left  of  the  sternum  at  the  second  or  third  intercostal  space 
(Roger).  It  is  transmitted  also  to  the  back,  but  not  to  the  carotids.  If 
the  opening  is  not  too  small,  the  pulmonic  second  sound  is  accentuated, 


DISEASES  OF  THE  HEART  397 

because  the  stronger  left  ventricle  forces  blood  into  the  right  and  thus  in- 
creases the  pressure  on  this  side. 

The  heart  may  remain  of  normal  size  for  many  years.  Eventually,  mod- 
erate dilatation  and  hypertrophy  of  the  right  ventricle  may  develop.  Usu- 
ally there  is  no  cyanosis.  The  general  health  and  the  physical  strength 
are  usually  not  impaired,  so  that  the  anomaly  is  generally  discovered  by 
accident  and  the  affected  individual  may  live  to  old  age. 

The  diagnosis,  during  infancy,  is  often  made  quite  definitely  from  the 
rough  systolic  murmur  heard  over  the  entire  heart  area,  with  its  maximal 
point  to  the  left  of  the  sternum.  There  is  no  purring  quality  to  the  mur- 
mur and  no  increase  in  the  cardiac  dulness.  The  distinct  or  accentuated 
pulmonic  second  sound  and  the  absence  of  cyanosis  differentiate  the  con- 
dition from  pulmonary  stenosis. 

The  diagnosis  becomes  much  more  difficult  when  the  same  symptoms 
are  initially  discovered  at  the  age  of  four  to  six  years.  At  this  period, 
acquired  mitral  insufficiency  becomes  more  and  more  common  and  gives 
similar  signs  on  auscultation  and  percussion.  The  maximal  location  of  the 
point  of  intensity  of  the  murmur  at  the  apex,  the  lesser  diffusion  of  the 
sound  and  its  diminished  roughness,  indicate  mitral  insufficiency. 

Very  frequently  the  open  septum  is  associated  with  congenital  pulmo- 
nary stenosis  or  a  patent  ductus  arteriosus,  or  with  both  of  these  anomalies 
at  the  same  time;  so  that  an  exact  diagnosis  often  meets  with  insuper- 
able difficulties. 

A  permanently  patent  foramen  ovale  is  a  rather  common  finding.  It 
may  be  present  without  causing  any  disturbances  producing  symptoms. 
Theoretically,  an  auricular  diastolic,  i.  e.,  ventricular  systolic  murmur, 
should  appear,  but  in  reality  this  is  hardly  ever  observed. 

2.  PATENCY  O.F  THE  DUCTUS  ARTERIOSUS  (BOTALLI) 

The  closure  of  the  ductus  arteriosus,  normally  completed  during  the 
first  month,  may  be  delayed  by  disturbances  in  the  pulmonary  circuit, 
usually  in  the  form  of  atelectasis,  or  by  cardiac  lesions.  This  failure,  in 
association  with  other  anomalies,  is  not  uncommon. 

When  this  patency  occurs  alone,  the  open  ductus  causes  a  systolic  mur- 
mur increasing  during  the  first  year.  Its  maximal  intensity  is  in  the  pul- 
monary area  and  is  probably  caused  by  the  meeting  of  the  currents  from 
the  pulmonary  artery  and  the  aorta  (see  Figure  108) .  The  pulmonic  second 
sound  is  always  accentuated  because  the  aortic  pressure  is  superadded  to 
it.  The  systolic  murmur  is  transmitted  to  the  carotids  from  the  aorta.  In 
older  patients  a  palpable  thrill  may  often  be  detected  in  the  pulmonic  area 
and  in  the  jugulum  or  aortic  arch. 

When  the  condition  has  persisted  for  some  time  the  pulmonary  artery 
usually  becomes  dilated  and  gives  a  characteristic  dulness,  some  finger's 
breadth  in  width,  situated  to  the  left  of  the  sternum,  which  is  shown  as  a 
shadow  in  the  Roentgen  picture.  Later  the  right  ventriclemaybedilated  also. 

In  uncomplicated  cases  the  general  health  remains  for  a  long  time  unim- 


398 


TEXT-BOOK  OF  PEDIATRICS 


paired.    Usually  there  is  no  cyanosis.    Later  a  tendency  to  catarrhal  affec- 
tions shows  itself,  but  the  individual  may  live  for  some  decades. 

Diagnosis  may  be  made  from  the  above  picture.    Where  a  combination 
of  lesions  exists  it  is  often  quite  impossible. 

3.  PULMONARY  STENOSIS 

This  is  the  most  common  of  congenital  heart  lesions.    It  has  been  esti- 
mated that  three-fifths  of  the  cases  observed  during  the  first,  year,  and  as 


Innominate 

Rt.  Pulmon. 
Arch  of  Aorta 

Pulmon.  Art. 
Rt.  Auricle 


Lft.  Auricle 


Rt.  Ventricle 


Lft.  Ventricle 


Descending 

Aorta 

Fia.  108. — Heart  of  new-born  infant.    The  ductus  arteriosus  (Botalli)  is  still  open,  and  the  different 
mixtures  of  blood  in  the  arch  of  the  aorta  and  descending  aorta  are  shown  (Kollmann). 

many  as  four-fifths  of  those  of  later  discovery,  are  of  this  type.  Longer 
life  is  compatible  with  pulmonary  stenosis  than  with  any  other  congenital 
heart  lesion.  It  is  true  that  life  is  sustained  by  the  compensatory  influence 
of  other  lesions  which  take  care  of  the  blood-supply  to  the  lungs.  Thus  in 
cases  of  patency  of  the  ductus  arteriosus,  of  so  frequent  occurrence,  the 
lung  receives  its  blood  supply  in  part  from  the  aorta;  and  in  the  event  of 
an  open  septum  the  blood  which  cannot  flow  through  the  narrowed  pulmo- 
nary orifice  passes  into  the  left  ventricle  and  thence  into  the  aorta.  Com- 
plete atresia  of  the  artery  is  rare.  The  stenosis  may  be  situated  at  the 


DISEASES  OF  THE  HEART  399 

mouth  of  the  vessel,  or  beyond  it  in  the  conus  arteriosus,  or  outside  of  this 
in  the  pulmonary  stem. 

Symptoms. — A  systolic  murmur  is  heard  in  the  pulmonic  area  and  the 
pulmonic  second  sound  is  weakened  or  absent.  The  first  sound  is  indis- 
tinct. If  the  stenosis  is  marked,  the  murmur  may  be  wanting.  If  there 
is  a  coincident  defect  of  the  septum  the  blood  flows  from  the  right  to  the 
left  ventricle  and  thence  into  the  aorta,  and  thus  the  murmur  may  be  trans- 
mitted to  the  aorta  and  the  carotids.  If  the  pulmonary  stenosis  is  com- 
bined with  patency  of  the  ductus  arteriosus  the  second  pulmonic  sound  may 
be  accentuated  while  the  remaining  sign  of  the  open  ductus,  a  purring  mur- 
mur markedly  transmitted  to  the  carotids,  is  present.  In  the  course  of 
some  years  a  considerable  dilatation  and  hypertrophy  of  the  right  ventricle 
may  develop. 

Generally  there  is  marked  cyanosis,  increasing  whenever  the  child  cries. 
The  patient  may  become  a  very  dark  blue  indeed.  The  cyanosis  is  often 
noticed  immediately  after  birth.  In  time,  an  extreme  degree  of  the  drum- 
stick fingers  develops.  The  general  health  is  disturbed  by  dyspnoea,  by  a 
tendency  to  pulmonary  catarrh,  to  fainting  spells,  choking,  and  dizziness. 
Death  often  results  from  respiratory  disease,  associated  with  edema,  with 
special  liability  to  pulmonary  tuberculosis. 

4.  AORTIC  STENOSIS 

Aortic  stenosis  is  much  less  common  than  either  of  the  three  lesions 
already  reviewed.  The  constriction  occurs  near  the  mouth  of  the  vessel 
and  gives  symptoms  resembling  those  of  acquired  aortic  stenosis.  If  the 
construction  is  of  very  marked  degree  the  patient  seldom  lives  longer  than 
a  few  weeks  and  during  this  period  is  simply  kept  alive  by  the  flow  of  blood 
from  the  pulmonary  artery  through  the  patent  ductus  arteriosus. 

Stenosis  of  the  isthmus,  in  which  a  constriction  occurs  in  the  region  of 
the  opening  of  the  ductus  arteriosus  into  the  aorta  (isthmus  aortae,  Fig. 
108),  is  a  matter  of  more  important  study,  because  it  is  compatible  with 
long  life.  This  stenosis  is  hardly  ever  extreme  and  is  readily  compensated 
by  hypertrophy  of  the  left  ventricle.  A  systolic  murmur  is  heard  at  the 
upper  part  of  the  sternum,  in  association  with  which,  unlike  pulmonary 
stenosis,  there  is  no  diminution  of  the  pulmonic  second  sound.  Later  in 
life  a  characteristic  collateral  circulation  is  established.  In  its  develop- 
ment the  internal  mammary  artery,  the  intercostals  and  other  vessels  are 
markedly  enlarged,  in  order  to  supply  this  region  normally  receiving  its 
-blood  from  arteries  arising  below  the  arch  of  the  aorta.  These  enlarged 
vessels  become  palpable  and  visible.  In  comparison  with  the  greatly  con- 
gested carotids  and  the  arteries  of  the  upper  extremities  those  of  the  lower 
extremities  are  poorly  filled. 

5.  TRANSPOSITION  OF  THE  GREAT  VESSELS 

This  anomaly  is  rare.  In  this  event  the  aorta  arises  from  the  right  and 
the  pulmonary  artery  from  the  left  ventricle.  Its  chief  symptoms  are  the 
absence  of  murmurs,  a  high  grade  cyanosis,  and  an  accentuation  of  the 


400  TEXT-BOOK  OF  PEDIATRICS 

pulmonic  second  sound.  Life  is  sustained  only  through  the  agency  of  asso- 
ciated defects  of  the  interventricular  septum.  The  author  has  seen  a 
case  of  transposition,  with  defect  of  the  septum,  which  reached  the  age  of 
five  years. 

Among  other  congenital  heart  lesions,  tricuspid  stenosis  should  be  men- 
tioned. Mitral  lesions  in  combination  with  other  anomalies  of  the  heart 
are  not  uncommon.  Occasionally  the  heart  is  found  in  a  mesial  position. 
A  congenital  idiopathic  hypertrophy  of  the  heart,  causing  sudden  death 
during  the  first  or  second  year,  and  associated  with  enlargement  of  the  thy- 
mus,  has  been  described  several  times.  The  author  has  seen  rare  instances 
of  idiopathic  hypertrophy,  symptomatically  showing  marked  pallor,  attacks 
of  dyspnoea,  a  small  and  very  rapid  pulse,  and  terminating  fatally,  in  which 
it  was  not  possible  to  say  whether  the  huge  heart  was  congenital  or  acquired. 

ACUTE  ENDOCARDITIS 

If  acute  endocarditis  is  of  prenatal  origin,  its  results  are  generally  loca- 
lized at  the  junction  of  the  right  ventricle  and  the  pulmonary  artery.  It 
has  been  already  said  that  congenital  heart  lesions  depend,  in  part,  upon 
inflammatory  changes  and  that  those  which  are  definitely  known  to  be  due 
to  anomalies  of  development,  tend  in  postnatal  life  to  inflammatory  com- 
plications. In  the  latter  event,  the  diagnosis,  during  life,  cannot  be  defi- 
nitely made. 

If,  following  the  ordinary  custom,  the  inflammatory  diseases  of  the 
heart  are  discussed  as  separate  entities  and  under  the  terms  of  endocardi- 
tis, myocarditis,  and  pericarditis,  it  must  not  be  forgotten  that  in  actual 
experience  these  distinctive  forms  of  disease  are  more  rare  than  gen- 
eral carditis. 

Etiology  and  Occurrence. — The  acquired  form  of  acute  endocarditis 
is  very  rare  before  the  fifth  or  sixth  year.  After  this  age  it  becomes  more 
common  and  has  its  maximal  frequency  between  the  tenth  and  fifteenth 
year.  In  fact,  three-fourths  of  all  cases  in  youth  may  be  traced  to  acute 
rheumatism,  while  in  adults  from  one-third  to  two-thirds  of  the  number 
are  attributable  to  this  infection.  The  infrequency  of  the  disease  before 
the  fifth  year  is  explained  by  the  fact  that  rheumatism  itself  is  uncommon 
before  that  time.  But  very  few  children  who  are  affected  by  rheumatism 
and  chorea,  coincidently  or  successively,  escape  endocarditis  entirely. 
Those  who  suffer  from  chorea  alone  apparently  stand  a  better  chance  of 
avoiding  the  heart  complication  (Weill). 

Next  to  rheumatism  and  chorea,  scarlet  fever  is  the  most  common  cause 
of  the  endocarditis.  This,  contrary  to  the  reports  of  Pospischill,  seems  to 
be  quite  definitely  established.  All  the  other  contagious  diseases  are  occa- 
sionally causative  and,  among  them,  diphtheria,  angina,  tuberculosis  and 
erythema  nodosum  should  be  especially  mentioned. 

Attention  should  be  called  to  the  fact  that  rheumatism,  in  childhood, 
even  though  it  be  ever  so  mild  and  clinically  not  well  defined,  tends  to 
endocarditis  much  more  readily  than  it  does  in  the  adult.  Accordingly, 
endocarditis  is  almost  always  secondary.  A  seemingly  primary  attack  is 


DISEASES  OF  THE  HEART  401, 

generally  traceable  to  rheumatism  or  tuberculosis.  Various  micro-organ- 
isms must  be  considered  in  its  etiology.  The  most  common  is  the  streptococ- 
cus. In  some  insidious  cases  the  streptococcus  viridans  has  been  found 
(Schottmuller).  Next  in  frequency  are  the  staphylococci  and  the  pneumo- 
coccus;  then  the  typhoid  and  colon  bacilli;2  and  occasionally  the  gonococcus. 
The  organism  responsible  for  rheumatism  is  still  unknown. 

The  pathologic  anatomy  of  endocarditis  does  not  differ  essentially  from 
that  in  the  adult.  The  changes  in  the  valves  are  in  the  nature  of  fibrinous 
varicosities,  leading  either  to  constriction  or  ulceration.  In  the  child, 
slight  structural  changes  may  be  entirely  repaired  while  the  ulcerated  form 
is  very  rare. 

Symptoms. — If  endocarditis  does  not  develop  during  or  following  a 
recognized  disease,  it  is  often  the  first  manifestation  of  acute  rheumatism 
which  has  been  ushered  in  often  by  an  unobserved  angina.  If  the  initial 
causative  disease  does  not  obscure  the  characteristic  picture  of  acute  endo- 
carditis, listlessness,  pallor,  nausea,  and  loss  of  appetite  appear  at  its  onset. 
Usually  an  irregular,  often  remittent  fever  develops,  which  does  not  range 
very  high  and  may  sometimes  be  so  slight  that  it  is  discovered  only  upon 
repeated  use  of  the  thermometer.  Slight  subfebrile  temperatures,  contin- 
uing for  weeks  after  rheumatism  or  scarlet  fever,  are  not  infrequently 
seen.  When  the  patient  is  put  to  bed  this  temperature  disappears,  only 
to  reappear  when  he  is  allowed  to  leave  the  bed.  In  this  condition,  all  the 
signs  of  endocarditis,  that  is  of  a  valvular  lesion,  very  gradually  develop. 

In  the  child  the  mitral  valve  is  by  far  the  most  commonly  affected  and 
initially  its  aortic  flap.  At  the  onset  the  first  sound  is  diminished  at  the 
apex.  Soon  it  becomes  indistinct  and  is  replaced  later  by  a  murmur.  This 
is  either  of  a  blowing  character,  or  of  sighing,  soft  quality  and  sometimes 
is  transmitted  to  the  pulmonary  and,  less  frequently,  to  the  aortic  area. 
The  wonderful  reserve  power  of  the  child's  heart  often  makes  it  possible 
for  the  left  heart  alone  to  compensate  the  lesion  for  a  long  time,  so  that 
there  is  no  congestion  of  the  pulmonary  artery  and  accentuation  of  the 
pulmonic  second  sound  may  not  be  noted  for  a  long  period. 

The  aortic  valve  is  affected  much  less  frequently,  and  secondarily  to 
the  inflammatory  process  in  the  mitral.  This  happens  very  commonly  in 
endocarditis  of  long  standing  and  with  repeated  attacks  of  fever.  With 
this  extension,  a  systolic  murmur  is  at  first  heard  in  the  aorta.  A  diastolic 
sound  appears  later  when  contractions  have  formed. 

Tuley  and  Moore  report  a  case  of  congenital  endocarditis  in  a  boy  of  13  years  of  age, 
with  a  patent  foramen  ovale,  where  the  pulmonary  orifice  was  almost  obliterated  by 
pendulous  vegetations  and  wart-like  growths.  Only  three  similar  cases  are  recorded  in 
2400  medical  admissions,  with  only  .01  per  cent,  of  1050  cases  of  valvular  involvement 
showing  only  the  pulmonary  valve  involved.  Very  few  are  diagnosed  during  life. 

Percussion  may  show  normal  cardiac  dulness  for  a  long  time  and 
even  the  Roentgen  ray  may  not  show  any  enlargement.  Its  absence  is  to 
be  explained  by  the  power  of  resistance  of  the  child's  heart,  which  shows  a 

2  B.  Influenza  may  be  the  causative  agent  especially  during  pandemics  (Malloch 
andRhea). 
26 


402  TEXT-BOOK  OF  PEDIATRICS 

large  measure  of  reserve  strength  and  undergoes  dilatation  and  hypertro- 
phy at  a  much  later  period  than  in  the  adult. 

The  pulse  is  always  rapid,  but  commonly  shows  none  of  the  irregularity 
which  usually  indicates  myocardial  disease.  In  infancy  the  customary 
picture  varies  so  markedly  (Lempp-Finkelstein),that  a  diagnosis  is  hardly 
ever  made — a  failure  the  more  likely  because  the  disease  is  extremely  rare 
at  this  age.  At  this  early  period  the  chief  causative  factor  is  usually  sepsis, 
quite  often  arising  from  an  unimportant  rhinitis.  The  local  symptoms 
often  fail  the  diagnostician  in  these  cases,  since  no  murmur  is  audible 
throughout  the  course  of  the  disease  and  the  enlargement  is  observed  only 
a  little  while  before  death. 

Following  the  febrile  onset,  great  pallor  develops  which  may  pass  into 
cyanosis.  From  time  to  time,  in  fact,  serious  attacks  of  cyanosis  appear. 
The  respiration  becomes  more  and  more  rapid  and  deep,  without  any  evi- 
dent cause  in  the  lung  itself.  Clinically,  the  disease-picture  resembles  that 
of  miliary  tuberculosis  very  closely  and  the  differentiation  is  difficult. 
Most  cases  occurring  in  infancy  are  fatal  within  a  few  weeks. 

Its  course  is  variable.  Save  in  infancy,  the  disease  terminates  fatally 
only  if  it  takes  on  an  ulcerative  form,  or  if  it  is  complicated  with  pericar- 
ditis or  myocarditis,  and  particularly  with  the  former.  Usually  a  chronic 
valvular  lesion  results.  Differences  of  opinion  still  obtain  as  to  the  possibil- 
ity of  complete  recovery  with  full  restitution  of  the  injured  valves  to  their 
normal  state.  With  other  authors,  the  writer  is  fully  convinced  that  he  has 
often  seen  recovery  from  mitral  endocarditis.  In  such  an  event,  the  mur- 
mur gradually  disappears  after  some  weeks.  There  is,  then,  no  reason  to 
suppose  that  muscular  insufficiency  always  ensues  in  these  cases.  Of  course, 
with  recovery  it  is  hard  to  prove  that  there  has  been  a  true  endocarditis. 

Ulcerative  endocarditis  is  much  less  common  in  the  child  than  in  the 
adult.  This  is  a  really  surprising  fact,  because  sepsis  is  of  so  frequent  occur- 
rence in  the  early  years  of  life.  It  is  explained,  perhaps,  by  the  integrity 
and  good  nutrition  of  the  endocardium.  This  form  of  the  disease  may  seem 
sometimes  to  be  of  primary  origin  and  again  it  may  occur  as  a  sequence  of 
simple  valvular  lesions  or  in  combination  with  septic  disease  of  the  mouth 
or  bladder.  Its  clinical  picture,  strongly  resembling  typhoid  or  general 
sepsis,  is  sharply  defined.  The  disease  is  ushered  in  by  restlessness,  chills, 
and  irregular  temperature,  followed  by  delirium  and  other  grave  cerebral 
symptoms.  The  picture  is  not  completed,  however,  until  hemorrhagic  and 
purulent  emboli  in  the  skin  reveal  its  true  septic  character.  With  the  excep- 
tion of  the  greatly  accelerated  pulse  and  a  slight  cyanosis,  the  heart  signs 
may  be  negative  in  its  early  or  even  later  history.  Occasionally,  the  pres- 
ence of  murmurs  and  of  acute  dilatation  announces  the  correct  diagnosis. 
Death  results  in  from  one  to  three  weeks. 

The  diagnosis  of  acute  endocarditis  offers  many  difficulties.  First  of 
all,  the  numerous  accidental  and  muscular  murmurs  that  occur  in  febrile 
diseases  must  be  excluded.  If  careful  daily  examination  shows  a  gradually 
increasing  and  persisting  murmur,  constant  in  character,  appearing  in  the 


DISEASES  OF  THE  HEART  403 

course  of  some  other  disease,  the  diagnosis  of  endocarditis  may  be  accepted. 
The  differentiation  from  pericardial  sounds  is  made  as  it  is  in  the  adult. 

The  very  small,  delicate  nodules,  which  are  frequently  found  at  the 
free  edge  of  the  venous  valves  in  children  during  the  first  years  of  life,  must 
not  be  mistaken  for  endocardial  exudates.  These  Albini's  nodules  may  be 
very  numerous.  Formerly,  they  were  erroneously  described  as  inflam- 
matory processes  in  autopsies  following  deaths  from  diphtheria.  In  the 
new-born,  discrete,  dark  violet  hematomata,  of  pinhead  size,  are  quite 
commonly  found  on  the  valves.  They  represent  capillary  ectasias  and 
disappear  as  the  valves  become  more  vascular.  They  are  of  no  signifi- 
cance whatever. 

The  prognosis  is  clear  in  the  b'ght  of  the  facts  already  cited.  Prophy- 
laxis must  be  directed  against  angina,  among  other  things,  and  care  must 
be  taken  to  see  that  even  the  mildest  and  seemingly  unimportant  cases  of 
afcute  rheumatism  receive  a  thorough  course  of  salicylates. 

Treatment. — In  the  matter  of  therapy  it  is  well  to  begin  with  a  course 
of  salicylates  in  any  case  where  rheumatic  symptoms  exist  or  appear  (see 
Acute  Rheumatism).  As  long  as  the  heart  is  normal  this  therapy  can  cer- 
tainly do  no  harm  and  may  protect  the  heart.  As  soon  as  acute  endocar- 
ditis is  suspected,  the  patient  must  be  kept  in  bed  and  treated  in  every  way 
as  though  the  disease  were  actually  established.  The  child  should  be  kept 
as  quiet  as  possible  and  avoid  all  unnecessary  motion.  He  should  not  be 
permitted  to  sit  up  even  to  take  food.  With  fever  and  greatly  accelerated 
heart  action  it  is  customary  to  apply  an  ice-bag.  The  author  has  never 
been  convinced,  however,  of  its  usefulness,  unless  it  be  that,  at  times,  it 
enables  the  child  to  be  still  for  a  longer  period.  With  the  infant,  and  par- 
ticularly when  there  is  no  fever,  it  should  certainly  be  omitted.  Tepid 
baths  carefully  given  are  to  be  preferred.  If  there  is  great  restlessness  and 
a  sense  of  fear,  codein  and,  in  older  children,  morphin,  give  required  rest 
and  beneficial  sleep.  Ordinary  cases  will  usually  do  without  cardiac  stim- 
ulants, such  as  digitalis,  etc.,  although  they  must  sometimes  be  consid- 
ered. In  severe  cases  such  stimulants  as  camphor  and  caffein  cannot  be 
avoided  (see  page  416). 

The  food  should  be  fluid,  or  semifluid  in  character,  consisting  chiefly  of 
milk,  soups,  thin  flour  puddings,  fruit  juices,  mashed  potato  and  soft  stewed 
apples.  Coffee,  tea  and  alcohol  should  not  be  used. 


Valvular  lesions  are  almost  always  the  results  of  acute  endocarditis 
and,  therefore,  indirectly  of  infectious  diseases.  The  exact  terminus  of  an 
acute  endocarditis  is  hardly  ever  determined  clinically.  The  possibility  of 
its  transition  into  an  insidious  chronic  endocarditis  is  always  to  be  taken 
into  account. 

According  to  a  number  of  authors  the  primary  chronic  endocarditis  of 
tuberculosis,  developing  at  puberty,  usually  produces  a  pure  mitral  steno- 
sis. In  childhood  arteriosclerosis,  as  a  cause  of  heart  lesions,  is  a  negligi- 


404  TEXT-BOOK  OF  PEDIATRICS 

ble  matter.  By  far  the  most  common  cause  is  acute  rheumatism;  the  endo- 
carditis associated  with  it,  preceding  the  recognition  of  a  valvular  lesion, 
often  runs  its  course  unnoticed. 

Valvular  lesions  occur  almost  without  exception,  only  after  the  fifth 
year.  The  very  occasional  departure  from  this  rule  is  noted  between  the 
second  and  fourth  years. 

The  Clinical  Picture. — Mitral  lesions  are  by  far  the  most  common  in 
childhood,  exceeding  aortic  disease  fifteen  or  twenty  fold.  Aortic  lesions 
seldom  appear  until  puberty.  The  clinical  picture  is  governed,  therefore, 
in  large  part  by  these  mitral  lesions  and  of  these  mitral  insufficiency  is  much 
the  more  prominent.  A  pure  mitral  stenosis  is  found  but  rarely  and  then 
only  in  older  children. 

It  is  a  quite  characteristic  fact  that  many  heart  lesions  remain  wholly 
latent  for  years  and  often  only  manifest  themselves  toward  puberty.  This 
is  true  in  about  one-half  of  the  cases  observed.  The  physician  discovers 
the  condition  quite  accidentally  in  the  course  of  a  general  examination. 
The  parents  have  not  suspected  any  trouble  with  the  child's  heart  or  even 
that  he  is  not  so  strong  and  healthy  as  other  children.  He  has  attended 
school  andengaged  in  gymnastics,  marchingandother  exercises.  Frequently, 
however,  the  patient  is  found  to  be  a  little  irritable;  he  tires  easily,  is 
pale,  and  now  and  then  complains  of  headache  and  has  frequent  epis- 
taxis.  Seldom  is  his  physical  development  delayed  and  this  generally 
in  the  rare  event  of  mitral  stenosis. 

Upon  examination  a  distinctly  visible  and  palpable  apex  beat  is  observed. 
It  is  to  be  noted  that  the  patient  himself  does  not  notice  the  forcible  beat 
and  that  the  young  child  hardly  ever  complains  of  palpitation.  If  the  con- 
dition has  existed  for  a  long  time  bulging  of  the  thorax  in  the  cardiac  region 
may  be  observed,  particularly  in  the  very  young  patient  or  in  initially 
severe  forms  of  the  disease.  Many  cases,  however,  show  no  deformity 
whatever.  Percussion  may  reveal,  for  years,  a  quite  normal  relationship 
and  at  the  most  only  a  slight  enlargement  of  the  heart  dulness  to  the  left, 
as  a  result  of  a  dilatation  of  the  left  ventricle  which  has  occurred  early  and 
completely  compensates  the  lesion  for  a  long  period.  The  nutritive  integ- 
rity of  the  heart  of  the  young  child;  the  absence  of  alcoholic  injuries  and 
of  arteriosclerosis;  the  low  blood-pressure  and  freedom  from  the  overexer- 
tion,  unite  to  make  complete  compensation  possible  for  years  and  to  post- 
pone congestion  of  the  pulmonary  or  systemic  circulation. 

The  murmurs  are  at  times  distinct  or  may  be  rough  and  sharp.  They 
are  heard  not  only  in  the  usual  areas  but  always,  in  the  very  young  and  gen- 
erally in  older  children,  over  the  back  between  the  scapula  and  particularly 
at  its  angle.  In  mitral  lesions  the  sound  is  lower  and  in  aortic  cases  higher 
than  ordinary. 

When  the  lesion  is  no  longer  compensated,  evidences  of  congestion  in 
the  pulmonary  and  systemic  circuits  soon  appear.  Enlargement  of  the 
liver,  cyanosis,  bronchitis,  dilatation  of  the  peripheral  veins,  a  true  venous 
pulsation  due  to  relative  insufficiency  of  the  tricuspid  valve,  effusion  into 
the  various  body  cavities,  and  edema  are  the  chief  results.  The  heart  is 


DISEASES  OF  THE  HEART  405 

notably  dilated,  especially  upon  the  right  side,  so  that  upon  first  examina- 
tion one  may  suspect  the  presence  of  a  pericardial  exudate.  At  first  the 
pulse  is  but  rarely  arhythmic  and,  even  later,  if  the  myocardium  is  not 
affected  arhythmia  may  not  appear. 

The  symptoms  of  the  various  valvular  lesions  are  generally  similar  to 
those  that  are  seen  in  the  adult  and  only  a  few  points  require  mention. 

Mitral  insufficiency  is  by  far  the  most  common  of  these  lesions  and  fre- 
quently occurs  independently.  The  accentuation  of  the  pulmonic  second 
sound  and  a  dilatation  of  the  right  ventricle  may  be  absent  for  a  long  time. 

Mitral  stenosis  generally  follows  upon  mitral  insufficiency  after  it  has 
existed  for  some  years.  In  these  cases  it  is  often  found  that  the  original 
systolic  murmur  has  disappeared,  being  entirely  replaced  by  a  diastolic 
murmur  with  fremitus.  The  author  has  never  seen  a  true  primary  stenosis 
develop  until  puberty.  As  in  the  adult  the  murmur  may  be  audible  only 
after  exertion. 

On  the  aortic  side,  insufficiency  and  stenosis  are  usually  coincident. 
The  valve  is  rarely  affected  until  the  tenth  to  the  twelfth  year.  This  form 
of  disease  is  often  of  severe  degree  and  dangerous.  It  may  terminate  in 
sudden  death. 

Tricuspid  insufficiency  is  seen  in  association  with  severe  mitral  lesions 
in  which  compensation  has  failed,  causing  dilatation  of  the  right  ventricle. 

Course. — From  the  writer's  personal  observation,  in  harmony  with  the 
reports  of  many  recognized  authorities,  it  may  be  said  that  in  acquired 
valvular  lesions,  and  especially  in  the  slight  mitral  insufficiency  of  child- 
hood, there  is  the  possibility  of  complete  restitution.  This  remains  true 
even  in  cases  in  which  the  diagnosis  is  very  well  established  (see  page  391); 
and  when  only  such  cases  are  considered  where  a  murmur  has  appeared 
very  gradually,  in  connection  with  acute  rheumatism,  and  has  remained 
unchanged  for  months  or  even  for  a  year  or  two,  it  has  been  known  to  dis- 
appear gradually  and  spontaneously.  In  most  cases,  of  course,  the  lesion 
once  developed  remains,  even  though  it  may  be  fully  compensated  and 
may  create  no  symptoms  for  many  years  and  usually  not  until  puberty,  or 
even  later.  Often,  however,  serious  disturbances  arise,  after  many  years 
of  undisturbed  well-being.  These  may  be  due  to  the  gradual  weakening 
of  the  heart  muscle  itself,  or  to  the  fact  that  the  heart  cannot  respond  to 
increased  demands  made  upon  it,  or  to  an  aggravation  of  the  heart  lesion 
incident  to  renewed  attacks  of  endocarditis. 

Frequently  the  disease  proves  fatal  within  a  few  months  or  years.  In 
these  cases,  however,  the  preexisting  heart  lesion  is  hardly  ever  responsible 
for  the  calamity,  the  cause  of  which  is  usually  to  be  found  in  a  supervening 
and  often  obliterative  pericarditis,  with  an  associated  myocarditis. 

In  general  it  may  be  said  that  valvular  lesions  are  compensated  more 
fully  and  for  a  longer  time  in  children  than  in  adults.  When,  however,  evi- 
dence of  compensatory  failure  once  appears  the  condition  is  always  a  serious 
one  and  death  results  more  speedily  than  in  older  persons.  Sometimes  the 
dilatation  of  the  heart  and  the  congestion  of  the  liver  are  enormous. 


406  TEXT-BOOK  OF  PEDIATRICS 

Diagnosis. — The  diagnosis  of  valvular  lesions  is  to  be  made  in  the  same 
manner  as  in  the  adult,  excepting  for  the  fact  that  recognition  of  mitral 
insufficiency,  difficult  in  older  persons,  offers  insuperable  obstacles  in  the 
child.  Accidental  systolic  murmurs  (see  page  390),  occur  so  commonly 
between  the  ages  of  five  and  fifteen,  that  we  can  hardty  be  careful  enough 
in  making  a  diagnosis  of  mitral  insufficiency  where  the  classical  symptoms 
are  not  distinct  and  when  the  murmur  is  not  loud  and  rough.  Since  in  the 
mitral  insufficiency  of  childhood  the  accentuation  of  the  pulmonic  second 
sound  and  the  enlargement  of  the  right  ventricle  may  appear  very  late 
and,  furthermore,  since  recovery  is  possible,  the  diagnosis  becomes  all  the 
more  difficult. 

Next  to  a  continuing  systolic  murmur  in  the  mitral  area,  the  lift  and 
the  resistant  quality  of  the  apical  impulse,  unchanged  with  the  changing 
position  of  the  body,  and  indicating  hypertrophy  of  the  left  ventricle,  is 
to  be  considered  a  symptom  of  the  greatest  importance.  The  attention  of 
the  reader  has  already  been  called  to  the  similarity  of  the  symptoms  of 
mitral  insufficiency  and  those  of  a  congenitally  open  septum  (see  page  396). 
In  anemic  school  children,  the  absolute  cardiac  dulness  is  often  enlarged; 
and  the  coincidence  of  anemic  murmur  may  easily  lead  to  the  mistaken 
diagnosis  of  an  organic  lesion  if  one  does  not  realize  that  the  enlargement 
of  the  absolute  dulness,  with  unchanged  relative  dulness,  may  be  due  to 
a  diminished  expansion  of  the  borders  of  the  lung. 

The  prognosis  is  already  clear.  Prophylaxis  should  consist,  first  of  all, 
in  the  avoidance  of  attacks  of  angina  or  acute  rheumatism,  by  the  observ- 
ance of  a  general  hygiene  and  especially  by  careful  conservation  of  the 
heart.  The  very  mildest  case  of  rheumatism  should  be  carefully  treated 
by  rest  in  bed  and  the  use  of  salicylates. 

Treatment. — An  existing  heart  lesion  which  is  fully  compensated  re- 
quires no  treatment.  If  the  physician  accidentally  discovers  such  a  lesion 
he  should  inform  the  parents,  without  directing  the  child 's  attention  to  its 
presence.  It  is  not  necessary  to  change  the  patient's  mode  of  life.  Severe 
physical  exercise,  and  especially  bicycle  riding,  which  is  apt  to  have  an 
injurious  effect  upon  the  heart,  must  be  forbidden.  Alcohol,  coffee,  and 
tea,  all  injurious  stimulants,  must  be  avoided.  The  patient  should  not 
select  any  means  of  livelihood  which  requires  strenuous  exertion.  Con- 
sidering the  tendency  of  rheumatism  and  endocarditis  to  recur,  all  expo- 
sure to  cold  is  to  be  safeguarded.  Gentle  measures  tending  to  increase  the 
patient's  resistance,  and  the  use  of  woolen  underclothing  in  the  cold  season 
are  to  be  recommended.  Country  life  may  serve  to  strengthen  the  child; 
a  benefit  to  be  gained  equally,  in  the  author's  estimation,  for  those  whose 
compensation  is  complete,  from  a  long  sojourn  in  the  mountains,  provided 
that  strenuous  hill-climbing  is  avoided. 

When  compensation  begins  to  fail,  long  periods  of  rest  in  bed,  with  car- 
bon dioxide  baths,  taken  either  at  home  or  at  some  resort,  may  be  tried. 
During  the  rest  treatment,  a  special  dietary  consisting  largely  or  exclusively 
of  milk  may  be  continued  for  seven  or  eight  days  with  good  results.  If 
despite  these  methods  there  is  continued  failure  or  a  want  of  full  compen- 


DISEASES  OF  THE  HEART  407 

sation  a  systematic  course  of  treatment  with  digitalis  should  no  longer  be 
delayed  (see  page  416).  This  drug  and  such  similar  remedies  as  camphor, 
caffein,  morphin,  etc.,  may  be  employed  as  they  are  in  the  adult. 

ACUTE  PERICARDITIS 

Etiology  and  Occurrence. — Mild  cases  of  pericarditis,  in  the  form  of 
slight  exudates  or  small  fibrinous  placques,  are  very  commonly  found  at 
autopsy  following  deaths  due  to  the  various  infectious  diseases  of  child- 
hood. More  intensive  forms  of  pericarditis,  of  larger  clinical  interest,  are 
also  seen  at  this  age.  In  the  new-born  and  in  young  infants  purulent  peri- 
cardia! exudates  occur  in  the  course  of  sepsis.  These  are  commonly  of 
streptococcic,  and  rarely  of  gonococcic  origin.  Even  at  a  later  period,  as 
late,  indeed,  as  the  fifth  to  the  seventh  year,  purulent  exudates  of  the  peri- 
cardium are  quite  usual,  but  they  generally  arise  from  inflammatory  process 
of  pneumococcic  type  in  the  neighboring  lung  tissue  or  pleura.  Exten- 
sion from  peritoneal  infections  is  less  frequent.  After  the  sixth  to  the  eighth 
year,  serous  pericardial  exudates  become  more  and  more  common.  These 
are  due  to  rheumatism  or  tuberculosis,  and  undergoing  resorption  show  a 
great  tendency  to  obliteration  of  the  pericardium.  In  rheumatism  marked 
involvement  of  the  pericardium  usually  occurs  subsequent,  only,  to  repeated 
cardial  attacks.  Accordingly  in  the  child,  both  in  type  and  origin,  pericar- 
ditis presents  a  parallel  to  pleurisj'. 

Further  it  is  to  be  remembered  that  at  every  age  the  several  infectious 
diseases,  scarlet  fever,  measles,  erysipelas,  etc.,  not  infrequently  cause  peri- 
carditis which,  in  its  lesser  degree,  is  often  unrecognized  and  in  more  severe 
forms  may  develop  purulent  exudates,  etc. 

Pathologic  Anatomy. — An  exudate  due  to  the  streptococcus  is  usually 
of  a  seropurulent  character.  In  pneumococcic  infection,  the  exudate  is 
less  abundant,  but  both  layers  of  the  pericardium  are  apt  to  be  covered 
with  thick,  ragged,  fibrinous  masses.  In  the  tuberculous  form  there  is  a 
large  amount  of  exudate,  but  comparatively  few  tubercles.  The  heart 
muscle  is  often  enormously  hypertrophied  and  dilated,  a  condition,  however, 
usually  resultant  from  rheumatism  and  due,  in  part,  to  valvular  lesions. 

Symptoms. — Acute  pericarditis  readily  escapes  notice  when  it  is  co- 
incident with  any  serious  primary  disease;  which,  aggravated  by  the  per- 
icarditis, may  even  cause  death  without  the  recognition  of  the  pericardial 
condition.  It  may  be  readily  understood,  therefore,  that  in  sepsis  or  other 
serious  infection,  pericarditis  may  often  go  unobserved.  It  is  equally  true 
that  in  pneumonia  or  pleurisy  the  area  of  dulness  incident  to  the  primary 
disease  covers  that  which  may  be  due  to  pericarditis.  Such  a  complication 
of  pneumonia,  by  no  means  a  rare  occurrence  in  early  years,  is  more  often 
announced  by  the  sudden  aggravation  of  the  general  symptoms  and  the 
remarkably  sudden  failure  of  the  pulse  than  by  any  physical  signs. 

In  cases  of  purulent  pericarditis  alone  making  up  the  clinical  picture, 
fever,  restlessness,  a  sense  of  thoracic  pressure,  dyspnoea  with  very  rapid 
respiration,  a  small  and  very  frequent  pulse,  an  anxious  countenance,  a 


408  TEXT-BOOK  OF  PEDIATRICS 

marked  pallor  with  ashen  color  and,  later,  cyanosis  occur.  As  in  other 
forms  of  pericarditis  sudden  death  may  result. 

In  acute  rheumatism,  the  picture  of  pericarditis  is  relatively  clear.  In 
the  rheumatism  of  children,  pericarditis  is  more  frequently  of  early  appear- 
ance than  it  is  in  the  adult.  Such  general  symptoms  as  fever,  restlessness, 
headache  and  anorexia  are  first  observed.  In  the  course  of  several  days,  a 
slight  friction  sound  may  be  discovered,  perhaps,  over  the  precordium.  It 
is  very  soft  and  may  resemble  an  endocardial  murmur,  but  is  of  changeable 
quality;  it  is  not  transmitted  and  occasionally  increases  under  the  pressure 
made  by  the  stethoscope.  In  contrast  to  an  endocardial  murmur,  it  is 
generally  heard  over  the  base.  Simultaneously,  or  a  little  later,  the  respira- 
tion increases  in  frequency  and  becomes  dyspnoeic  and  sighing.  The  pulse 
grows  small  and  frequent.  Increasing  pallor  and  restlessness  emphasize 
the  seriousness  of  the  disease-picture,  although  complaint  of  thoracic  or 
precordial  pressure  may  still  be  lacking.  Careful  examination,  however, 
reveals  an  increase  of  cardiac  dulness  in  typical  form,  extending  well  beyond 
the  apex:  to  the  left,  peaking  the  area  at  the  base  and,  a  peculiar  character- 
istic, widening  well  to  the  right  and  filling  the  cardiohepatic  angle,  a  result 
not  observed  in  simple  dilatation  of  the  right  ventricle.  The  development 
of  distinct  dulness  in  Traube's  space,  below  the  apical  impulse,  when  there 
are  no  indications  of  pleuritic  effusion,  is  an  extremely  important  point. 
Frequently  friction  sounds  are  heard  in  the  precordial  region  when  the 
exudate  is  large.  This  is  readily  explained  by  the  fact  that  the  abundant 
exudate  forces  the  heart,  which  cannot  be  pushed  backward,  against  the 
anterior  thoracic  wall.  The  greater  part  of  the  fluid  gathers  below,  to  the 
left,  and  to  the  right  of  the  heart.  If  the  exudate  is  very  large,  the  left  lung 
is  compressed — a  result  which  is  indicated  by  dulness  posteriorly  and  infe- 
riorly,  and  by  diminished  breathing  sounds,  or  bronchial  breathing.  These 
pseudopneumonic  and  pseudopleuritic  manifestations  are  quite  common. 
It  often  happens,  however,  that  a  pleural  effusion  develops  prior  to,  or 
coincidently  with,  or  subsequent  to,  a  pericardial  exudate.  This  may 
occur  in  the  right,  or  the  left,  or  in  both  pleural  cavities;  and  if  it  is  of  early 
occurrence  it  may  mask  the  evidences  of  pericarditis.  The  concealment 
is  most  apt  to  occur  if  the  pleural  effusion  is  on  the  left  side.  The  apical 
impulse  will  often  be  felt  longer  than  might  be  supposed.  If  the  exudate 
is  large  a  general  undulation  of  the  entire  precordial  region  may  be  observed. 
Under  these  circumstances,  and  particularly  in  young  children,  this  entire 
area  may  bulge  if  the  condition  has  existed  for  a  long  period.  The  left  half 
of  the  thorax  lags  in  inspiration.  A  large  exudate  makes  the  work  of  the 
heart  more  difficult,  especially  in  diastole.  Such  an  excessive  effusion  occurs 
almost  wholly  in  tuberculous  cases  and  quite  rarely  in  the  rheumatic  form. 

The  pulse  hi  this  condition  may  become  smaller  and  smaller  and  may 
reach  a  frequency  of  160  to  200.  The  congestion  may  cause  increasing 
cyanosis,  a  distension  of  the  veins  of  the  neck,  an  enlargement  of  the  liver 
which  may  be  painful  on  pressure,  and,  occasionally,  a  general  edema.  In 
favorable  cases  the  whole  condition  improves  with  the  resorption  of  the 
exudate.  If  this  does  not  ensue,  the  dyspnoea  and  the  pressure  symptoms 


DISEASES  OF  THE  HEART  409 

increase  and  death  comes  with  heart  failure  and  collapse  after  many  days 
or  weeks  of  suffering.    Sometimes  death  occurs  suddenly  and  unexpectedly. 

The  severity  of  the  disease  is  often  increased  by  a  coincident  rheumatic 
endocarditis.  Even  when  the  exudate  is  resorbed  recovery  is  not  neces- 
sarily assured.  Quite  often,  and  decidedly  more  often  than  in  the  adult, 
the  disease  results  in  more  or  less  complete  obliteration  of  the  pericardial 
sac,  which  bars  the  possibility  of  convalescence  and  results  in  a  long,  tedious 
illness  and  ultimately  in  death  (see  below) . 

Tuberculous  pericarditis  pursues  a  course  quite  similar  to  that  of  rheu- 
matic origin,  excepting  that  it  is  much  more  insidious  and  hence  of  more 
gradual  onset.  It  has  a  distinct  tendency  to  the  formation  of  a  massive 
exudate,  generally' of  a  serous  character.  The  disease  commonly  extends 
to  the  pleural  and  peritoneal  cavities  simultaneously.  It  often  arises  from 
so  small  a  focus  in  the  king  or  the  bronchial  nodes  that  it  appears  to  be  pri- 
mary in  the  serous  membranes. 

Diagnosis. — The  diagnosis  depends  upon  the  same  symptoms  as  in  the 
adult.  These  consist  of  the  large  triangular  area  of  cardiac  dulness;  the 
disappearance  of  the  angle  of  resonance  between  the  liver  and  the  heart; 
and  the  filling  in  of  Traube's  space  beneath  the  heart.  The  progressive 
increase  of  the  area  of  dulness  is  especially  characteristic,  as  is  also  the 
gradual  approach  of  the  absolute  to  the  relative  dulness.  In  a  word,  the 
absolute  dulness  enlarges  more  rapidly  than  the  relative. 

Occasionally  in  young  children,  when  the  exudate  is  small,  a  diagnosis 
is  very  hard  to  make.  A  fibrino-purulent  pericarditis,  associated  with  pleur- 
fey  and  pneumonia,  often  defies  demonstration.  Roentgen  examination 
is  very  conclusive  in  exudative  pericarditis,  showing  a  markedly  enlarged, 
non-pulsating  silhouette,  with  disappearance  of  the  cardio hepatic  angle. 
By  means  of  the  X-ray  it  is  also  possible  to  distinguish  the  extreme  cardiac 
dilatation  which  may  occur  in  older  children  in  scarlet  fever  and  other  infec- 
tious diseases. 

If  the  existence  of  an  exudative  pericarditis  is  definitely  established,  it 
is  rarely  difficult  to  determine  whether  the  exudate  is  of  a  serous  or  a  puru- 
lent character,  and  that  even  without  a  blood  examination.  If  pus  be  pres- 
ent, a  count  will  show  a  distinct  increase  of  leucocytes.  In  early  childhood 
a  serous  exudate  is  hardly  ever  seen,  while  later  this  is  the  predominant 
type  on  account  of  its  usual  rheumatic  or  tuberculous  origin.  At  this  early 
age  the  purulent  forms  are  seen  only  in  severe  cases  of  infectious  or  respira- 
tory disease. 

An  exudative  pericarditis  which  is  apparently  primary  will  prove  actu- 
ally secondary  either  to  rheumatism,  to  tuberculosis,  or  more  rarely  to  neph- 
ritis. If  endocarditic  murmurs,  with  other  coincident  or  earlier  symptoms 
of  rheumatism,  are  absent,  the  condition  is  usually  tuberculous. 

The  prognosis  of  purulent  pericarditis  is  almost  inevitably  a  hopeless 
one.  In  any  exudative  form  it  is  always  very  serious,  since  the  disease 
frequently  results  in  immediate  death  or  in  obliteration  of  the  pericardium. 
In  rheumatic  cases  it  may  be  said  that  death  usually  results,  directly  or 
indirectly,  from  obliteration  of  the  pericardial  sac. 


410  TEXT-BOOK  OF  PEDIATRICS 

Treatment — The  treatment  of  acute  pericarditis,  even  in  its  purely 
fibrinous  form,  and  most  certainly  in  its  exudative  types,  dictates  absolute 
rest  in  bed.  If  there  is  reason  to  suspect  its  rheumatic  origin,  the  salicy- 
lates  should  be  given  from  the  very  beginning  and  will  prove  as  useful  as 
they  are  in  the  rheumatic  exudate  of  pleurisy.  To  children  of  five  years, 
0.3  gm.  (grs.  v),  of  acetylsalicylate  may  be  given,  three  times  daily;  while 
for  children  of  ten  years,  0.5-0.7  gm.  (grs.  viii-x),  of  acetylsalicylic  acid, 
three  times  a  day,  may  be  substituted.  With  older  children,  an  ice-bag 
may  be  placed  over  the  heart  if  the  fever  is  high.  Often  it  has  a  quieting 
effect,  but  beyond  this  its  value  is  rather  doubtful.  Later,  applications  of 
heat  are  to  be  preferred. 

The  patient's  head  should  be  kept  high.  All  excitement  and  exertion 
are  to  be  avoided.  During  the  acute  stage  the  diet  should  be  light  and 
readily  digested,  consisting  chiefly  of  milk,  gruels,  soups,  toast,  rolls,  eggs, 
apple  sauce,  and  vegetables. 

Cardiac  weakness  and  increasing  congestion  require  heart  stimulants, 
in  the  form  of  digitalis,  caffein,  or  camphor  (see  page  416).  Morphin, 
by  mouth  or  subcutaneously,  is  most  serviceable  if  there  is  great  restless- 
ness and  sense  of  thoracic  pressure  and  will  aid,  also,  in  quieting  the  heart. 
Its  use  should  not  be  too  long  delayed.  If  the  pericardia  exudate  is  very 
large,  surgical  interference  must  be  considered.  In  the  event  of  a  purulent 
exudate,  probably  the  only  satisfactory  measure  is  resection  of  a  rib  and 
drainage  of  the  pericardium;  but  in  view  of  the  hopelessness  of  the  prog- 
nosis it  is  a  measure  to  which  resort  is  very  occasionally  had.  With  mas- 
sive serous  exudates,  however,  paracentesis  of  the  pericardium  should  be 
practiced  more  commonly  than  it  is  at  present.  The  extra  mammary  me- 
thod of  Curschmann  seems  to  the  writer  by  far  the  best.  An  exploratory 
puncture  is  first  made  in  the  fifth  intercostal  space,  at  least  one  centimeter 
outside  of  the  apical  impulse,  but  in  the  area  of  absolute  dulness.  If  the 
apex  beat  cannot  be  felt,  the  puncture  is  made  just  inside  of  the  outer 
border  of  absolute  dulness,  the  needle  passing  in  a  sagittal  direction  or 
slightly  inclined  toward  the  median  line.  If  the  exudate  is  reached,  a  larger 
but  very  sharp  needle  is  inserted  in  the  same  place,  permitting  the  fluid  to 
pass  off  freely  but  as  slowly  as  possible.  The  especially  designed  trocars  of 
Curschmann  may  be  dispensed  with.  The  passage  of  the  needle  through 
the  pericardium  gives  a  sensation  similar  to  that  caused  by  pricking  a  dis- 
tended bladder.  The  drainage  of  the  exudate  occurs  more  readily  if  the 
needle  is  connected  with  a  fine  rubber  tube  filled  with  salt  solution,  with 
the  free  end  extending  below  the  level  of  the  body.  This  procedure  is  simple 
and,  carefully  performed,  is  quite  free  from  danger  and  often  achieves 
wonderful  results  in  lifting  the  load  from  the  compressed  heart.  The  author 
has  removed  by  this  method  500  c.c.  of  fluid  from  the  enormously  enlarged 
pericardial  sac  of  a  six-year-old  boy.  In  this  instance  there  could  have 
been  no  possibility  of  confusion  of  the  pericardial  exudate  with  a  coinci- 
dent pleural  exudate,  since  the  latter  was  of  a  different  color. 


DISEASES  OF  THE  HEART  411 

PERICARDIAL  ADHESIONS 

The  termination  of  pericarditis  in  the  complete  obliteration  of  both  the 
visceral  and  parietal  layers  of  the  pericardium  deserves  special  mention 
because  it  is  relatively  common  in  children  between  the  ages  of  eight  and 
ten  years.  In  these  cases  the  preceding  acute  pericarditis  frequently  goes 
unrecognized  and  the  clinical  picture  is  often  overshadowed  by  symptoms 
other  than  those  which  point  to  the  heart.  Most  of  them  occur  in  the 
course  of  rheumatic  affections.  Hypertrophy  and  dilatation  of  both  ven- 
tricles are  so  great  that  the  enlargement  of  the  heart  area  seems  to  be  fully 
explained,  and  a  possible  exudate,  rarely  of  very  great  quantity,  easily 
escapes  observation.  Second  to  rheumatism,  tuberculosis  plays  an  impor- 
tant role  in  the  etiology  of  this  condition.  In  this  class  of  cases  the  valves 
are  usually  intact,  the  initial  exudate  is  quite  large,  and  the  resulting  oblit- 
eration of  the  pericardium  is  less  readily  recognized. 

The  pathologic  findings  usually  show  a  firm  knitting  together  and  thick- 
ening of  both  layers  of  the  pericardium  throughout  its  entire  area  or  over 
a  large  part  of  its  surface.  In  recent  cases,  the  gelatinous  character  of  the 
exudate  is  shown,  occasionally,  in  spots.  If  the  process  is  tuberculous,  tuber- 
cles or  caseated  masses  may  be  found  between  the  layers  of  the  pericardium. 
Death,  in  cases  of  rheumatism,  is  usually  a  result  of  obliterative  pericar- 
ditis, so  that  this  is  a  very  common  finding  at  autopsy.  At  times  the  outer 
layer  of  the  pericardium  is  adherent  to  the  pleura,  the  sternum,  or  the 
mediastinum,  the  whole  being  converted  into  a  dense  cicatricial  mass. 

Symptoms. — Many  cases  are  latent  throughout  their  entire  course  and 
are  discovered  only  at  autopsy.  This  failure  of  diagnosis  occurs  chiefly  in 
cases  of  rheumatic  nature.  In  these  patients  it  is  often  impossible  to  dis- 
tinguish the  symptoms  which  are  consequent  upon  the  existing  heart  lesion 
from  those  which  relate  to  the  pericardial  adhesions.  Valvular  lesions  and 
heart  murmurs  are  almost  always  present;  together  with  a  marked  and 
often  enormous  hypertrophy  and  dilatation  of  both  ventricles,  which  press 
against  a  large  area  of  the  thoracic  wall.  A  distinct  impulse  over  the  entire 
cardiac  area  and  a  bulging  of  the  thorax  are  to  be  regarded  as  results  of 
this  hypertrophy.  The  apex  beat  is  generally  definite.  A  systolic  retrac- 
tion of  the  apical  area  is  indicative  of  adhesions  between  the  heart  and  the 
thoracic  wall.  This  is  not  to  be  confused,  however,  with  the  more  common 
systolic  retraction  of  the  intercostal  space  in  the  immediate  region  of  a 
forcible  apex  beat  (Romberg).  The  diastolic  rebound  of  the  intercostal 
spaces  is  pathognomonic,  but  it  may  be  mistaken  readily  for  the  apex  beat. 
It  is  apparent  that  signs  by  which  obliteration  of  the  pericardium  may  be 
recognized  demand  a  very  careful  examination  and,  even  at  that,  diagnosis 
may  fail  in  the  major  number  of  cases. 

The  general  symptoms  of  extreme  pallor,  superficial  respiration,  thor- 
racic  pressure,  a  small  pulse,  cardiac  hypertrophy  and  dilatation,  are  just  as 
common  in  endo-  and  myocarditis,  or  in  cases  of  valvular  lesion,  as  they 
are  in  pericardial  disease.  It  follows  that  obliteration  is  to  be  suspected 
only  when  convalescence  from  pericarditis  does  not  occur.  In  fact,  the 


412  TEXT-BOOK  OF  PEDIATRICS 

child  always  becomes  a  chronic  sufferer.  As  long  as  the  patient  is  kept  in 
bed,  his  condition  remains  fair,  although  the  pulse  is  very  small  and  fre- 
quent and  the  respiration  becomes  dyspnoeic  upon  the  slightest  exertion. 
But  as  soon  as  the  child  is  permitted  to  get  up,  the  heart  is  found  to  be  insuf- 
ficient in  spite  of  the  enormous  hypertrophy.  The  pericardia!  adhesions 
serve  as  a  powerful  obstacle  to  normal  heart  action  and  this  obstacle  is  well- 
nigh  insurmountable  when  the  heart  becomes  attached  to  the  sternum,  a 
result  which  cannot  be  overcome  by  hypertrophy.  The  patient  grows  very 
weak,  dyspnceic  and  cyanotic,  and  returns  to  bed  of  his  own  accord.  There- 
after, periods  of  improvement  and  aggravation  alternate;  the  child  feeling 
fairly  well  for  months  at  a  time,  or  being  able,  perhaps,  to  go  to  school  occa- 
sionally. Generally  speaking,  alike  in  the  rheumatic  and  tuberculous  forms, 
attacks  of  fever,  with  pleural  exudate  and  peritoneal  effusion,  recur  from 
time  to  time.  The  disease  gradually  becomes  more  and  more  aggravated 
and  terminates  with  bronchitis  and  edema,  as  the  results  of  cardiac  insuf- 
ficiency, after  months  or  even  years  of  time. 

If  the  physician,  and  especially  one  who  is  inexperienced,  has  not  ob- 
served the  premonitory  symptoms  of  pericarditis,  his  attention  is  often 
diverted  from  the  heart  by  the  frequent  appearance  of  abdominal  symp- 
toms. Of  these  the  most  marked  is  the  noticeable  enlargement  and  indur- 
ation of  the  liver,  which  is  often  tender  to  the  touch.  The  hepatic  border 
may  be  three  or  four  fingers'  breadth  below  the  costal  margin.  Since  this 
is  often  accompanied  by  enlargement  of  the  spleen  and  ascites  one  may  be 
tempted  to  suspect  a  primary  cirrhosis  of  the  liver.  This  is  a  very  easy 
error  to  fall  into,  particularly  when  percussion  and  auscultation  show  fairly 
normal  heart  outlines,  as  happens  frequently  in  tuberculous  pericarditis. 
The  mistake  may  be  avoided  if  due  attention  is  given  to  the  usually  evident 
cyanosis,  to  the  small  rapid  pulse,  the  dyspnoea,  and  the  readily  demon- 
strated pleural  effusion  or  thickening.  Later  on,  in  rheumatic  cases,  very 
marked  cardiac  changes,  with  a  mitral  murmur,  tricuspid  insufficiency, 
and  dilatation  are  hardly  ever  wanting. 

This  so-called  pericarditic  pseudocirrhosis  of  the  liver  is  probably  to 
be  considered  as  a  symptom  of  congestion,  in  the  causation  of  which  the 
constriction  of  the  inferior  vena  cava  by  the  rigid  pericardium  plays  a  part. 

This  conception,  however,  is  not  to  be  considered  as  definitely  estab- 
lished, for  the  liver  lesion  is  quite  frequently  absent,  while  again  it  may 
occur  independently  of  any  cardiac  affection.  Nevertheless,  exudative  or 
fibrinous  inflammatory  processes  in  the  pleural  cavity  and  adhesions  of  the 
liver  to  its  surroundings,  as  in  tuberculosis,  are  found  relatively  often  in 
relation  to  pericarditis.  A  symptom-complex  due  to  chronic  hyperplastic 
perihepatitis  is  also  occasionally  encountered.  In  many  cases,  and  not 
uncommonly  among  older  children,  it  seems  necessary  to  assume  that  there 
is  a  form  of  polyserositis  involving  the  pericardium  and  causing  cirrhotic 
changes  in  the  liver. 

Diagnosis. — The  difficulties  in  diagnosis  of  obliteration  of  the  pericar- 
dium have  been  made  sufficiently  clear.  In  cases  in  which  neither  friction 
sounds  nor  evidence  of  exudate  can  be  made  out,  the  diagnosis  must  often 


DISEASES  OF  THE  HEART  413 

remain  tentative.  Even  at  autopsy  the  tuberculous  nature  of  the  disease 
cannot  always  be  demonstrated. 

In  making  a  differential  diagnosis  true  valvular  lesions,  with  myocar- 
ditis and  with  indurated  enlargements  of  the  liver  of  varying  etiology,  in 
which  lues  is  to  be  included,  must  be  considered. 

The  prognosis  is  clear.  The  disease  is  fatal,  it  may  be  after  weeks, 
months  or  even  years  of  suffering.  Partial  adhesions  only  are  compatible 
with  long  life  but,  antemortem,  they  arehardly  ever  definitely  demonstrable. 

Treatment. — Treatment  is  very  unsatisfactory.  Several  authors  claim 
to  hare  seen  marked  improvement  with  the  use  of  fibrolysin  injections. 
Cardiolysis,  the  operative  measure  designed  by  Brauer,  may  prove  useful 
if  the  pericardium  is  adherent  to  the  sternum  and  may  be  considered  if  the 
general  condition  of  the  patient  is  not  unfavorable.  In  the  child,  however, 
the  hope  of  success  is  slight.  Accordingly  it  is  better,  as  a  rule,  to  confine 
oneself  to  the  usual  symptomatic  treatment  of  existing  cardiac  insufficiency 
(see  page  416).  Digitalis  often  entirely  fails  of  results  because  the  myocar- 
dium is  seriously  affected.  Large  pleural  or  peritoneal  effusions  must  be 
tapped.  Rest  and  the  best  of  care  and  of  food  are,  of  course,  essential.  In 
mild  cases  carbon  dioxide  baths  may  be  tried. 

MYOCARDITIS  AND  CARDIAC  INSUFFICIENCY 

Acute  myocarditis  often  accompanies  various  infectious  diseases,  espe- 
cially diphtheria,  scarlet  fever  and  sepsis,  and  occasionally  pertussis,  ty- 
phoid fever,  etc.  In  rheumatism,  the  disease  often  develops  coincidently 
with  endocarditis,  so  that  the  old  term  carditis  or  pancarditis  is  quite 
appropriate.  But  rarely  is  myocarditis  primary,  and  even  when  it  is  appar- 
ently so  it  will  often  be  traced  to  some  general  infection  which  has  failed 
of  earlier  recognition. 

Chronic  myocarditis  is  much  less  frequent  in  the  child  than  in  the  adult ; 
since  arteriosclerosis,  so  commonly  associated  with  it,  does  not  occur  in  the 
young.  It  is  occasionally  found  in  relation  to  the  infectious  diseases;  most 
frequently,  of  course,  accompanying  valvular  lesions  and  less  often  with 
obliteration  of  the  pericardial  sac. 

Pathologically  the  heart  muscle  in  acute  myocarditis  is  found  to  be 
indurated  and  of  a  yellow  color  or  streaked  with  yellow.  The  microscopic 
changes  are  often  more  pronounced  than  might  be  expected  from  the  macro- 
scopic findings.  Degenerative  changes  of  the  muscle  fibre,  with  round  cell 
infiltration,  occur.  In  the  chronic  form,  placqucs  similar  to  those  occa- 
sionally seen  in  syphilis  and  in  tuberculosis,  may  be  found. 

Symptoms. — The  symptoms  of  acute  myocarditis  are  often  very  indefi- 
nite and  are  apt  to  be  hidden  by,  and  quite  indistinguishable  from  the 
symptoms  of  primary  infectious  disease  with  which  it  is  associated.  Its 
manifestations  are  definite  only  when  they  outlast  the  acute  fever.  Not 
infrequently  the  progress  of  the  disease  is  wholly  latent  and  sudden  car- 
diac death  may  be  the  result. 

The  most  important  indications  are  the  diminution  of  the  heart's  force 
and  the  small,  rapid  pulse.  Bradycardia  is  rare.  The  weak  pulse  of  acute 


414  TEXT-BOOK  OF  PEDIATRICS 

infectious  disease  is  generally  regarded  as  a  sign  of  the  weakness  of  the 
heart  muscle.  Very  often,  however,  it  is  rather  the  result  of  a  toxic  vaso- 
motor  injury  and  the  heart  muscle  itself  may  be  entirely  normal.  Pallor, 
restlessness,  dyspnoea,  and  even  cyanosis  may  be  caused  by  either  form  of 
disturbance.  The  apex  beat  and  the  heart  sounds  are  usually  weakened 
in  myocarditis;  the  second  sound  may  even  disappear;  and  one  or  both 
ventricles  may  become  dilated.  Systolic  murmurs  are  due  to  relative  insuf- 
ficiency. Enlargement  of  the  liver  is  one  of  the  earliest  indications  of 
resulting  congestion.  Peripheral  edema,  on  the  other  hand,  is  rare.  The 
blood-pressure  falls;  the  pulse  often  becomes  irregular,  but  is  seldom  slow. 
Protein  is  frequently  found  in  the  urine  as  a  result  of  the  primary  disease. 
Sensations  of  constriction  and  pain  in  the  chest,  indicating  heart  disease, 
are  much  less  common  than  in  adults. 

Myocarditis  occurring  in  diphtheria  presents  a  peculiar  quality  which 
will  be  discussed  under  that  disease. 

The  serious  cardiac  disturbances  sometimes  developing  in  scarlet  fever 
are  probably  traceable  to  myocarditis.  The  extremely  rapid  pulse  fre- 
quently observed  in  ordinary  attacks  of  this  disease  seems  to  indicate  a 
peculiar  affinity  of  the  scarlatinal  toxin  for  the  heart  muscle.  This  is  fur- 
ther suggested  by  the  bradycardia  often  found  during  the  second  week;  by 
the  cardiac  dilatation  and  the  transitory  murmurs  which,  according  to 
Stolte  and  Lederer,  are  of  atonic  origin.  These  cases  in  which  a  rapid  pulse 
and  cardiac  insufficiency  continue  for  many  weeks  after  the  subsidence  of 
temperature  are  probably  of  myocardial  character. 

Typhoid  fever  causes  myocardial  degeneration  much  more  frequently 
in  children  than  in  adults,  in  spite  of  its  usually  mild  degree.  It  is  rarely, 
however,  a  cause  of  death  in  this  disease.  The  arhythmia  which  develops 
in  convalescence  from  this  and  many  other  infectious  disorders,  even  though 
the  primary  disease  is  not  of  severe  grade,  is  probably  due  to  the  slight 
myocardial  changes  of  a  transitory  type. 

Chronic  myocarditis  occasionally  develops  after  acute  infectious  dis- 
eases and  most  frequently  after  diphtheria.  Tachycardia,  arhythmia  of  the 
small  pulse,  very  rarely  bradycardia  and,  at  times,  dilatation  are  observed. 

The  most  serious  symptom  is  an  increasing  insufficiency  of  the  cardiac 
muscle,  seen  in  the  later  stages  of  valvular  lesions,  in  which  it  is  usually  the 
ultimate  cause  of  death.  It  occurs  most  commonly  in  acute  and  chronic 
myocarditis.  Its  well-known  indications  are  the  dilatation  of  the  right 
heart,  a  decreased  blood-pressure,  dyspnoea,  cyanosis,  enlargement  of 
the  liver  and  ascites.  Peripheral  edema  is  very  frequently  absent  or  it  ap- 
pears late. 

In  rheumatic  pancarditis,  obliteration  of  the  pericardial  sac,  with  the 
obstacles  which  it  places  in  the  way  of  normal  heart  action,  and  the  accom- 
panying myocarditis  are  chief  causes  of  insufficiency.  Many  conditions, 
on  the  contrary,  which  cause  cardiac  insufficiency  in  the  adult,  e.  g.,  pulmo- 
nary emphysema,  arteriosclerosis,  fatty  heart  and  contracted  kidney  are 
wholly  negligible  in  the  child. 


DISEASES  OF  THE  HEART  415 

Diagnosis. — The  diagnosis  of  myocarditis  is  often  extremely  difficult, 
especially  during  the  fever  period  of  acute  infectious  diseases  when  a  feeble 
pulse  is  often  due  to  vasomotor  disturbances.  Consequently  it  is  often  an 
obscure  question  whether  the  primary  symptom-complex  is  to  be  attributed 
to  an  organic,  a  toxic,  or  a  dynamic  injury.  Into  the  problem,  the  possible 
impairment  of  the  peripheral  or  central  nervous  mechanism  and  of  the 
intrinsic  heart  ganglia  enter.  In  diphtheria  it  is  especially  difficult  to  de- 
termine to  what  extent  a  primary  disturbance  of  the  heart  action  depends 
upon  disease  of  the  myocardium  or  upon  disease  of  the  vagus. 

The  muscular  tone  response  in  the  heart  chamber,  is  shown  by  a  retraction  of  the 
antrium,  auricle  or  ventricle  following  a  series  of  twenty  strokes  with  the  percussion 
hammer  of  from  1  to  2  centimeters  inside  of  the  previous  outline.  If  the  patient  is 
horizontal  and  an  attendant  passively  elevates  the  legs  to  an  angle  of  75-80°,  and  allows 
the  child  to  lower  them  slowly,  the  auricles  retract  in  a  heart  with  normal  muscle  tone, 
while  if  there  is  myocardial  weakness  the  auricles,  or  both  auricles  and  ventricles  di- 
late (Minerbi). 

The  symptoms  of  myocarditis  are  often  similar  to  those  of  recent  endo- 
carditis. Of  course  the  two  diseases  are  frequently  coexistent.  In  scar- 
let fever,  acute  dilatation  due  to  nephritis  is  sometimes  mistaken  for 
myocarditis. 

The  prognosis  of  myocarditis  is  always  doubtful.  In  diphtheria  one 
must  always  be  prepared  for  sudden  death.  The  prognosis  of  cardiac  insuf- 
ficiency in  the  chronic  heart  diseases  of  childhood  is  even  less  favorable 
<than  in  the  adult.  It  must  be  said  that  compensated  heart  lesions  in  chil- 
dren have  a  more  favorable  course  than  they  show  in  later  life,  but  that  when 
failure  of  compensation  occurs  it  is  less  susceptible  of  permanent  recovery 
and  more  rapidly  fatal  (Weill). 

Treatment. — In  the  matter  of  treatment  the  uncertainty  of  diagnosis 
is  not  of  so  great  importance,  for  up  to  the  present  time  therapy  is  purely 
symptomatic  and  must  be  directed  to  the  cardiac  insufficiency  and  the 
consequent  disturbances  of  the  circulation. 

The  treatment  of  acute  myocarditis  and  of  cardiac  weakness  in  acute 
infectious  diseases  must  aim  primarily  to  protect  the  heart  and  to  avoid 
injuries  from  without.  Absolute  rest  in  bed  and  the  avoidance  of  all  excite- 
ment, such  as  may  be  attendant  upon  unnecessary  painting  of  the  throat 
in  diphtheria,  are  demanded.  Antipyretics,  with  the  possible  exception  of 
quinine,  and  alcoholics  are  injurious  and  must  be  avoided  entirely.  Tepid 
baths  act  favorably  upon  the  heart.  In  older  children,  with  fever,  ice-bags 
cold  compresses,  or  ice-coils  are  often  pleasant  and  quieting  and  will  prob- 
ably have  a  tonic  influence. 

The  diet  should  be  light,  fluid  or  semifluid,  preference  being  given  to 
milk  but  it  should  be  moderate  in  quantity  and  excess,  particularly  of  fluids 
should  be  avoided. 

Digitalis  is  of  doubtful  value  in  the  cardiac  weakness  of  acute  myocar- 
ditis and  should  be  employed  only  in  cases  in  which  other  remedies  have 
failed.  Of  the  cardiac  or  vascular  stimulants,  camphor  and  caffein  are  most 


416  TEXT-BOOK  OF  PEDIATRICS 

satisfactory.  Their  exhibition  should  not  be  delayed  too  long  if  the  pulse 
becomes  markedly  weak  or  if  severe  pallor,  dyspnoea  and  cyanosis  develop. 

Caffein  sodio-salicylate  may  be  given  in  doses  of  0.05-0.15  gm.  (grs. 
i-iii),  each  day,  to  infants;  0.2-0.3  gm.  (grs.  iiiss-v),  to  children  of  three 
to  five  years;  0.4-0.8  gm.  (grs.  vii-x),  to  children  of  eight  to  ten  years. 
These  quantities  should  be  divided  into  three  to  five  doses  a  day.  Suf- 
ficiently diluted  with  water,  this  remedy  is  taken  without  objection  by 
the  patient;  it  is  well  borne,  and  hardly  ever  causes  excitement. 

Camphor  is  preferably  given  subcutaneously.  It  may  be  administered 
from  three  to  eight  times  daily  in  doses  of  seven  to  ten  minims  of  the 
ten  per  cent,  solution  in  oil.  The  official  spirits  of  camphor  may  be 
employed  in  the  same  manner,  but  it  causes  necroses  if  not  carefully 
injected  intracutaneously. 

If  the  circulation  is  very  bad,  strychnia  may  be  tried,  giving,  once  a  day 
and  subcutaneously,  0.0005  gm.  (gr.  H2u),  in  the  first  year;  0.001  gm.  (gr. 
Mo),  to  children  of  three  to  six  years;  and  0.002  gm.  (gr.  Mo),  to  older 
children.  With  the  strychnia,  an  epinephrin  solution,  (1:1000),  may  be 
given,  using  0.5-1.0  c.c.  (minims  viiss-xv),  in  10.  c.c.  (5 iiss),  of  physiologic 
salt  solution. 

Often  the  best  results  are  obtained  with  the  combined  treatment,  so 
that  there  is  no  objection  to  using  caff  em  and  camphor  together,  each  in 
smaller  doses  and,  if  necessary,  adding  strychnia  or  epinephrin  also. 

If  no  results  are  obtained  from  this  therapy,  the  liquor  digitoxini  solu- 
bilis  (digalen),  may  be  tried  intramuscularly,  using  0.5  gm.  (minims  viiss), 
for  very  young  children;  and  1.0  gm.  (minims  xv),  for  older  ones. 

As  in  adults,  digitalis  is  the  sovereign  remedy  in  cases  of  cardiac  insuf- 
ficiency in  chronic  heart  disease  and  in  the  event  of  the  failure  of  compen- 
sation in  valvular  lesions.  The  usual  caution,  however,  must  be  observed 
and  even  more  religiously  in  children. 

Children  under  three  years  of  age  may  be  given  6  c.c.  (5i),  of  the  infu- 
sion, once  a  day  for  two  days;  while  children  of  five  to  seven  years  may  be 
given  12  to  25  c.c.  (5iii-v),  in  the  same  way.  The  action  of  the  fresh  digi- 
talis leaves  is  even  more  certain,  0.02  gm.  (gr.  %),  in  the  powdered  form, 
being  given  three  times  a  day  to  children  under  three  years;  0.04-0.07gm. 
(gr.  %j-i),  to  older  children.  Its  use  may  be  continued  for  four  or  five  days. 
As  soon  as  the  dyspnoea  decreases,  and  a  free  diuresis  occurs  and  the  pulso 
is  distinctly  slowed,  the  treatment  must  be  stopped.  The  newer  prepara- 
tions give  very  good  results  and  they  are  borne  better  by  the  stomach  than 
the  original  drugs.  Liquor  digitoxini  solubilis,  or  digalen,  may  be  given  in 
doses  of  0.1  c.c.  (minims  ii),  three  times  a  day,  to  children  in  the  first  two 
j^ears;  and,  as  often,  in  doses  of  0.2-0.5  c.c.  (minims  iii-viii),  to  older 
children.  This  remedy  may  also  be  given  intramuscularly  or  per  rectum. 
Digipuratum  is  given  in  doses  of  0.02  gm.  (gr.  ^£),  to  0.04-0.06  gm.  (gr.  %j-i), 
according  to  age,  three  times  a  day.  It  is  a  very  reliable  drug  and  as  certain 
in  action  as  the  leaves.  It  does  not  have  any  bad  effect  upon  the  stomach. 

It  is  best  to  give  the  digitalis  preparations  for  three  to  five  successive 
days  only.  If  necessary  caffein,  in  the  prescribed  doses  or,  preferably  if 


DISEASES  OF  THE  HEART  417 

there  be  marked  dropsy,  a  theobromin  preparation,  such  as  diuretin 
[0.1-0.5  gm.  (grs.  iss-viiss),  three  times  a  day],  may  be  substituted  in  the 
intervals.  If  the  stomach  will  not  tolerate  this  medication  it  may  be  given 
by  rectum.  In  cases  of  dangerous  cardiac  insufficiency,  in  which  the  usual 
digitalis  therapy  would  act  too  slowly,  strophanthin,  0.00025-0.0005  gm. 
(gr.  Mso  to  ^25),  in  a  single  dose  only,  may  be  used  to  advantage  in 
older  children. 

In  congenital  lesions  the  use  of  digitalis  should  be  delayed  so  long  as  pos- 
sible, employing  it  only  when  increasing  dyspnoea  and  congestion  indicate 
the  beginning  of  cardiac  insufficiency.  In  cases  of  open  septum,  digitalis 
may  be  injurious  on  account  of  the  increased  pressure  in  the  pulmonary 
circulation,  when  the  stronger  left  ventricle  forces  more  blood  into  the 
already  overworked  right  ventricle. 

In  cases  of  cardiac  dropsy,  in  which  digitalis  and  diuretin  have  failed, 
a  combination  of  digitalis  with  calomel  [0.03-0.06  gm.  (gr.  ss-i.),  three 
times  a  day]  will  often  prove  efficient  and  cause  a  free  flow  of  urine  after 
three  or  four  days  of  treatment. 

In  obliteration  of  the  pericardial  sac  the  myocardium  is  often  so  com- 
pletely exhausted  that  digitalis  proves  useless. 

When  severe  cardiac  symptoms,  as  restlessness,  dyspnoea,  orthopncea, 
a  sense  of  constriction,  etc.,  occur,  the  little  patient  should  not  be  denied 
the  beneficial  effect  of  morphin  which,  under  such  conditions,  is  peculiarly 
restful  to  the  heart.  It  is  best  given  subcutaneously  in  doses  of  0.001-0.002 
gm.  (gr.  M-M),  for  children  of  two  to  four  years;  and  of  0.003-0.004  gm. 
(gr-  fyr%\  for  children  of  six  to  ten  years,  increasing  the  dose  until  the 
desired  results  are  secured. 

APPENDIX 

BLOOD-VESSELS  AND  JUVENILE  HEART 

Diseases  of  the  blood-vessels  are  not  of  great  moment  in  children,  since 
arteriosclerosis  occurs  only  exceptionally  and  in  the  later  years  of  child- 
hood. It  is  true  that  a  mild  degree  occurs  occasionally  in  young  children 
and  even  in  infancy  (Saltykow),  but  it  is  without  clinical  significance. 

Aortitis  and  aneurism  of  the  aorta,  due  to  hereditary  lues,  have  been 
seen  in  children  of  eight  to  twelve  years. 

Only  about  20  cases  of  aneurisms  of  the  thoracic  aorta  in  children  are  on  record. 
Rupture  of  the  aneurism  has  been  the  cause  of  death  in  8  cases  (Bronson  and  Sutherland). 

Arterial  emboli,  on  the  contrary,  are  not  uncommon  in  acute  and 
chronic  affections  of  the  heart,  and  particularly  following  diphtheria. 

During  puberty  one  frequently  sees  disturbances  which  are  regarded 
as  due  in  part  to  peculiarities  constituting  the  so-called  "juvenile  heart." 
Children,  so  conditioned,  complain  of  palpitation,  a  sense  of  pressure  in 
the  thorax,  and  of  shortness  of  breath.  Combined  with  these  symptoms 
there  may  be  a  heaving  apex  beat  and  an  accentuated  pulmonic  second 
sound  and  occasionally  even  a  systolic  murmur.  An  enlargement  of  the 
27 


418  TEXT-BOOK  OF  PEDIATRICS 

area  of  cardiac  dulness,  together  with  firm,  tortuous  arteries  may  be  found ; 
the  latter  leading  one,  however,  to  think  rather  of  a  functional  stiffening 
than  of  a  juvenile  arteriosclerosis.  The  blood-pressure  is  not  increased. 
The  Roentgen  ray  reveals  no  actual  enlargement  of  the  heart,  as  one  may 
have  been  led  to  suspect.  In  fact  the  heart  is  more  likely  to  be  smaller  than 
normal,  and  it  may  occasionally  resemble  the  "drop  heart,"  with  aorta  of 
small  calibre,  seen  in  narrow-chested  individuals,  presenting  the  signs  of 
general  infantilism.  A  true  narrowing -of  the  aorta  is,  however,  extremely 
rare  and  its  significance  in  relation  to  these  accompanying  conditions  has 
not  been  explained.  In  these  disturbances  of  the  juvenile  heart  it  is  usually 
only  a  question  of  reduced  functional  capacity,  relationally  to  the  age  of 
the  child,  or,  in  other  words,  a  disproportion  in  growth.  Such  anomalies 
do  not  always  disappear. 

It  must  be  remembered  that  masturbation  may  cause  exaggerated  and 
rapid  heart  action. 


VI. 
DISEASES  OF  THE   GENITO -URINARY  SYSTEM 

C.  NOEGGERATH 

Revising  the  section  by  L.  Tobler  in  the  first  four  editions. 

.      INTRODUCTION 

THE  study  of  the  diseases  of  the  urinary  apparatus  is  not  completed  by 
the  mere  demonstration  of  the  presence,  nature  and  amount  of  protein  and 
formed  elements  in  a  given  urine  specimen.  It  is  necessary  to  determine, 
further  the  location  of  the  disturbance,  whether  it  is  renal  or  extra  renal; 
glomerular,  tubular  or  interstitial.  This  is  shown  by  the  clinical  course. 
It  is  still  more  important,  however,  to  determine  the  degree  of  secretory 
disturbance — just  as  it  is  essential  to  determine  the  compensation  in  heart 
lesion — and  the  careful  study  of  other  organs  such  as  the  skin  (pallor,  edema 
perspiration) ;  the  body  cavities  (transudates) ;  the  eye  grounds,  the  nervous 
system ;  and  the  gastro-intestinal  tract ;  is  of  utmost  importance. 

As  a  part  of  the  latter,  the  determination  of  the  blood-pressure  is  one  of 
the  more  necessary  steps.  The  usual  methods,  with  cuffs  of  varying  size  to 
suit  the  age  of  the  patient,  are  employed.  The  following,  which  may  be 
considered  averages  for  different  ages,  are  given  in  millimeter  mercury :  nurs- 
lings: 108/80;  three  years:  110(118)/78;  six  years:  118  (125) /83;  eight  years: 
124  (129) /85;  after  the  ninth  to  eleventh  years  the  values  are  the  same  as 
in  the  adult,  134  (136) /95.  Here  the  first  figure  is  the  maximum  pressure 
as  determined  by  auscultation  or  oscillation,  the  second,  in  parenthesis, 
the  palpation  determination,  and  third  the  minimum.  The  pressure  of  the 
bed-ridden  is  lower  and  that  of  neurotic  individuals  higher. 

Even  in  childhood  the  increased  blood-pressure  differentiates  acute  and 
chronic  diffuse  glomerulitis  from  the  focal  forms  and  from  interstitial 
nephropathy  and  especially  from  tuberculous  nephritis.  In  consideration 
of  the  rather  wide  range  of  the  normal  pressure  and  the  great  frequency  with 
which  slight  variations  are  encountered,  the  single  record  is  not  nearly  as 
valuable  as  a  rise  or  fall  in  a  series  of  measurements  or  a  sudden  change 
from  a  formerly  recorded  measuring  of  the  pressure.  A  sudden  rise  may  be 
a  valuable  early  symptom  of  uremia. 

In  infancy  and  childhood,  the  various  changes  of  the  blood  itself,  such  as 
concentration,  reduction  of  the  protein,  etc.,  are  similar  to  those  of  the 
kidney  diseases  in  the  adult.  The  more  or  less  fixed  sodium  chloride  con- 
tent is  560  (540)  mg.  per  100  c.c.  serum.  The  combined  protein  equals  28-40 
mg.  per  100  c.c.  protein  free  serum — both  values  the  same  as  in  the  adult. 

The  functional  tests  are  to  be  obtained  by  determining  the  extra  and 
intrarenal  metabolism  of  water  as  shown  by  daily  record  of  the  body-weight. 
This  is  the  only  method  by  which  it  is  possible  to  show  the  retention  of 
water  in  the  internal  organs,  the  so-called  pre-edema  of  Widal.  To  this 
must  be  added  the  observation  of  the  specific  gravity  of  the  urine  and  the 
total  daily  quantity  as  compared  with  the  amount  of  water  ingested. 

419 


420  TEXT-BOOK  OF  PEDIATRICS 

After  the  third  or  fourth  day  after  birth,  the  total  daily  quantity  of 
urine  represents  a  definite  proportion  of  the  fluid  ingested.  While  this 
varies  in  individuals  and  at  different  periods,  the  averages  may  be  given  as 
follows:  For  every  100  c.c.  food  injected  the  new-bocn  secretes  60  c.c. 
urine;  the  nursing  infant  68  c.c.,  and  the  child  on  partial  solid  diet  and 
throughout  childhood,  70  c.c.  (Camerer).  The  total  daily  quantity  of  urine 
and  the  specific  gravity  are  subject  to  great  variations.  During  the  first 
year  100  to  500  c.c.  of  a  specific  gravity  1.004  to  1.010  are  secreted.  During 
the  second  year  600  c.c.  of  1.006-1.012  specific  gravity.  During  the  third  to 
fifth  years,  500-800;  from  the  fifth  to  eighth,  600-1200  of  1.004-1.012 
specific  gravity;  and  from  the  eighth  to  fourteenth  years,  800  to  1500  c.c. 
of  a  specific  gravity  of  1.002  to  1.024  (Holt). 

Pollakiuria  is  physiologic  in  the  nursling.  The  power  of  concentration  and 
dilution  of  the  urine  is  present  at  birth,  but  the  concentration  found  in  the 
adult  does  not  occur  before  the  end  of  the  first  or  beginning  of  the  second 
year.  After  this  the  interpretation  of  variations,  except  as  shown  by  the 
normals  above,  is  as  in  the  adult.  This  is  also  true  of  polyuria,  oliguria  and 
anuria  alone  or  combined  with  disturbances  of  dilution  and  concentration. 

The  tolerance  tests  differ  but  slightly  from  those  used  in  adults.  For 
several  days  a  test  diet  of  sufficient  caloric  value,  with  reduced  protein,  poor 
in  sodium  chloride  and  containing  a  small  amount  of  water  adapted  to  the 
age  of  the  patient,  is  given.  This  means  a  milk  and  vegetable  diet  or  a  pure 
vegetable  diet,  or  in  very  young  infants,  breast-milk.  The  substance  for 
which  the  kidney  tolerance  is  to  be  tested,  water,  sodium  chloride,  protein, 
is  then  added  to  this  diet  in  quantities  sufficiently  great  to  more  than  supply 
the  normal  retention  of  growth  but  not  so  great  as  to  cause  injury  to  the 
patient.  Thus  200  to  1000  c.c.  water  may  be  added,  or  60-100  grams 
protein  in  the  form  of  calcium  caseinate,  or  1  to  5  grams  sodium  chloride. 
These  are  given  with  the  first  morning  feeding  after  emptying  the  bladder. 
The  secretion  of  these  substances  is  observed  as  in  the  adult  and  by  means 
of  it  the  specific  renal  efficiency  may  be  determined.  The  retention  of 
sodium  chloride  and  water  is  indicative  of  tubular  nephritis  and  the 
retention  of  the  end  products  of  protein  metabolism  indicates  glomeru- 
lar  nephropathy. 

UREMIA 

The  toxemia  caused  by  substances  of  unknown  origin,  that  may  be  formed 
in  the  urine,  occurs  in  the  two  forms,  as  follows : 

First:  Eclamptic  uremia,  more  common  in  childhood,  and  not  accom- 
panied by  nitrogen  retention,  is  probably  due  solely  to  the  retention  of 
sodium  chloride  and  water  in  the  tissues.  The  diarrhoea  and  vomiting  is 
the  natural  attempt  of  the  organism  to  free  itself  of  the  overload.  If,  how- 
ever, the  oliguria  causes  pressure  and  retention  of  sodium  chloride  in  the 
cerebrospinal  fluid  and  resulting  brain  edema,  the  symptoms  of  headache, 
slowing  of  the  pulse,  increased  reflexes,  Babinski's  sign,  and  even  uncon- 
sciousness to  coma  supervene.  If  the  brain  pressure  is  further  increased, 
the  blood-pressure  rises  suddenly  and  life  ends  in  an  eclamptic  seizure. 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         421 

The  general  tonic — clonic  twitchings,  wide  fixed  pupils  and  rapid  pulse 
resemble  the  symptoms  of  true  epilepsy  or  being  monoplegic  may  be  mis- 
taken for  Jacksonian  epilepsy.  Forms  with  chorea,  ataxia,  or  disturbances 
of  speech  are  seen. 

Very  frequently  the  condition  does  not  advance  beyond  the  early  symp- 
toms of  disturbed  reflexes.  These  often  indicate  the  beginning  of  polyuria 
and  recovery.  Contrary  to  expectation,  extreme  uremic  eclampsia  is  less 
often  met  with  in  tubular  nephritis  than  in  the  glomerular  form,  from  which 
it  would  seen  that  the  central  nervous  system  in  the  latter  cases  is  more  liable 
to  edema. 

Second:  The  form  of  uremia,  characterized  by  the  retention  of  nitrogen 
in  the  tissues  and  increased  blood  nitrogen  (azotemia)  dependent  upon 
unknown  urinary  toxins  is  seen  in  cases  of  total  anuria  such  as  caused  by 
double  obstruction  of  the  ureters,  hydronephrosis,  tumors,  and  in  extensive 
destruction  of  the  glomeruli  in  glomerular  nephritis.  The  most  important 
initiating  symptoms,  severe  headache,  sleeplessness,  anorexia  and  vomit- 
ing, should  serve  to  call  the  physician 's  attention  to  the  steadily  decreasing 
amount  of  urine  and  this  demands  prompt  interference.  Later  we  find  the 
heavily  coated  tongue,  an  odor  of  urine  on  the  breath  and  even,  occasionally 
ulcerative  stomatitis.  The  patient  is  tired  arid  somnolent  and,  as  a  result  of 
diarrhoea  and  nausea,  especially  when  offered  meat,  becomes  weak.  Grad- 
ually a  general  anesthetic  somnolence  (hence  " sleeping  uremia")  with 
reactionless  narrowed  pupils  appears.  This  may  be  accompanied  by  rest- 
lessness, panting  respiration,  fear  and  cardiac  distress.  The  reflexes  are 
increased  and  Babinski's  sign  is  present.  Blindness  of  one  or  both  eyes 
due  to  central  lesions  may  be  added  and,  finally,  general  uremic  convulsions 
form  the  climax  of  the  condition.  Recovery  may  occur  after  the  entire 
syndrome  or  during  any  part  of  the  course.  Or  the  outcome  may  continue 
in  a  more  chronic  form  to  a  fatal  end.  It  is  not  uncommon  to  find  a  mixed 
'  form  of  both  the  above  conditions  in  young  children. 

As  to  the  treatment  of  uremic  poisoning:  With  severe  headache, 
vomiting  and  marked  oliguria,  either  Irypo-  or  isotenuria,  liberal  phlebotomy 
(120-150-200  c.c.)  is  indicated.  In  chronic  cases  decapsulation  of  one  or 
both  kidneys  is  advised.  Lumbar  puncture  promptly  relieves  the  brain 
edema.  A  purely  carbohydrate  diet  aids  the  removal  of  the  poisoning.  By 
the  combination  of  these  energetic  measures  the  seriousness  of  acute 
uremia  in  childhood  has  lost  some  of  its  terrors. 

ORTHOTIC  ALBUMINURIA 

Very  small  amounts  of  protein  may  be  demonstrated  in  the  urine  of 
healthy  individuals  if  the  urine  be  evaporated  to  greater  concentration  and 
the  more  delicate  tests  be  applied.  The  demonstration  of  protein  by  the 
ordinary  clinical  tests  does  not  always  justify  the  supposition  that  the 
kidney  has  suffered  structural  changes,  even  though  the  proteinuria  be  of 
true  renal  origin  and  is  not  caused  by  the  mixture  with  the  urine  of  such 
protein-containing  fluids  as  blood  or  pus.  Von  Leube  has  found  noticeable 
quantities  of  protein  in  the  urine  of  one-third  of  the  healthy  soldiers 


422 


TEXT-BOOK  OF  PEDIATRICS 


examined,  the  proportion  being  increased  if  the  examination  was  preceded 
by  physical  exertion.  Other  authors  claim  to  have  found  proteinuria  after 
heavy  meals  or  cold  baths  and  even  after  excessive  mental  activity  or 
emotional  excitement.  Attempts  at  palpation  of  the  normal  kidney  often 
result  in  transitory  proteinuria.  If  children  of  a  certain  age  are  made  to 
kneel  in  an  upright  position  (see  Fig.  109)  for  a  short  time,  one-third  to  one- 
half  of  their  number  will  show  protein  in  the  urine,  often  in  considerable 
amounts.  Indeed  a  benign  form  of  proteinuria  is  very  frequent  at  this  age. 
The  phenomenon  appears  and  disappears  with  a  degree  of  regularity  and 


FIG.  109. — Relation  of  the  amounts  of  protein  (black)  in  the  urine  as  affected  by  posture.  Eleven- 
year-old  girl  with  orthotic  albuminuria;  (1)  Kneeling  with  marked  kyphosis;  (2)  Natural  standing  position, 
with  lordosis;  (3)  Increase  of  lordosis  on  kneeling;  (4)  Forced  lordosis,  standing. 

without  reference  to  any  particular  preceding  injury.  It  may  develop  as 
large  quantities  of  protein  as  a  true  nephritic  proteiuuria. 

From  these  facts  it  will  appear  that  a  gradual  transition  may  occur  from 
the  realm  of  health  to  conditions  that  must  be  considered  abnormal  and  it  is 
impossible  and  impracticable  in  this  particular  to  draw  a  definite  line 
between  health  and  disease.  Certainly  it  cannot  be  done  by  using  the 
amount  of  protein  in  one  or  more  specimens  of  the  urine  as  a  criterion. 
Comparison  of  the  conditions  under  which  a  proteinuria  appears  and  the 
general  state  of  the  individual's  health  will  probably  establish  a  more 
satisfactory  basis. 

The  functional  proteinuria  of  childhood  has  been  distinguished  from  the 
nephritic  form  by  several  names.  Pavy  who  first  described  the  condition 
applied  to  it  the  term  "cyclic,"  on  account  of  the  remarkable  regularity 
with  which  the  condition  appears  and  disappears  at  definite  hours  of  the 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         423 

day.  Stirling  proposed  the  designation  postural  in  order  to  emphasize  its 
most  essential  characteristic,  a  dependence  upon  the  erect  position  of  the 
body.  Orthostatic  albuminuria,  the  name  of  more  general  usage,  has 
practically  the  same  meaning,  while  the  older  designation  of  Heubner 
orthotic  albuminuria  suggests  more  nearly  the  nature  of  the  condition 
which  is  correctly  described  as  a  proteinuria  caused  by  "raising  oneself  to 
an  upright  position,"  or  rather  as  a  result  of  changing  from  a  horizontal 
to  a  vertical  posture,  in  spite  of  the  maintenance  of  which  the  proteinuria 
gradually  disappears. 

The  functional  proteinurias  are  common  during  the  same  period  in 
which  the  orthotic  type  occurs.  These  functional  forms  have  been  described 
under  various  names,  especially  by  the  French  authors.  The  latter  not 
only  distinguish  between  the  cyclic  and  orthostatic  types,  but  also  claim  to 
be  able  to  differentiate  hepatogenic,  alimentary  and  pretuberculous  forms. 

All  these  proteinurias  disappear  with  absolute  rest  in  bed.  Indeed 
they  are  all  influenced  by  posture  and  it  hardly  seems  possible  or  justi- 
fiable to  group  them  upon  solely  theoretical  grounds. 

Occurrence. — Orthotic  proteinuria  is  most  common  between  the  ages  of 
seven  and  fourteen  years.  It  is  very  rare  in  early  childhood  and  its  like- 
lihood of  occurrence  decreases  toward  puberty.  Its  greatest  frequency  is 
coincident  with  the  period  of  greatest  bodily  growth,  from  the  eleventh  to 
the  fourteenth  year.  The  affection  is  somewhat  more  common  among 
girls  than  in  boys.  The  figures  of  absolute  frequency  vary  greatly.  Reports 
of  different  observers  record  the  condition  in  from  5  to  30  per  cent,  of  all 
children  of  school  age  examined.  It  may  appear  in  several  members  of  a 
family  and  not  uncommonly  in  succeeding  generations. 

It  is  more  frequently  seen  in  the  large  families  of  the  needy,  living  in 
unhygienic  surroundings,  than  among  the  well-to-do.  Tuberculosis  and 
neuropathy  are  among  its  hereditary  antecedents,  but  no  definite  rules  of 
such  relationship  can  be  laid  down.  Scrofulous  and  tuberculous  children 
are  found  among  those  so  affected,  but  they  do  not  constitute  a  majority 
of  its  subjects. 

Symptoms. — Orthotic  proteinuria  is  often  discovered  in  the  course  of 
routine  examinations.  The  patient  comes  to  the  physician  complaining  of 
indefinite  symptoms  such  as  headache,  lassitude,  loss  of  interest  in  work  or 
play,  sleepiness,  attacks  of  dizziness  tending  even  to  fainting'spells,  anorexia, 
nausea,  and  occasional  vomiting.  Palpitation  of  the  heart,  side-ache,  and 
indefinite  pains  in  the  back  and  limbs,  the  so-called  "growing  pains, "are 
frequent  accompaniments.  A  history  of  epistaxis  is  common. 

Orthotic  proteinuria  is  often  encountered  in  strong,  healthy  looking 
boys  and  girls  who  have  grown  rapidly  and  developed  early.  An  individual 
predisposition,  which  we  may  anticipate,  does  not  necessarily  suggest  itself 
in  the  general  conditions  of  the  child.  The  majority  of  these  patients  are 
thin,  rather  weak  individuals  with  a  poorly  developed  panniculus.  Objec- 
tive symptoms  of  anemia  or  chlorosis  may  be  lacking  in  spite  of  their 
delicate  appearance  and  usual  pallor.  It  may  be  assumed  that  the  distri- 
bution of  the  blood  is  inadequate.  Other  signs,  in  fact,  indicate  anomalies 


424  TEXT-BOOK  OF  PEDIATRICS 

of  the  circulation.  This  view  of  a  functional  vascular  disturbance  is  best 
pictured  by  the  term  "irritable  weakness."  The  peripheral  circulation  is 
feeble,  the  extremities  are  cold  and  moist  and  there  is  marked  dermatog- 
raphia  and  recurrent  congestion.  Erythema  and  urticaria  are  common. 
The  pulse  is  labile  both  in  volume  and  in  frequency  and  is  at  times  dicrotic. 
The  heart  is  often  slightly  dilated,  but  this  may  be  simulated  by  such  a 
change  of  posture  as  a  dependence  of  the  head,  or  by  a  narrow  thorax. 
Radiograph!  cally  Reyher  has  demonstrated  the  small  "drop  heart"  more 
frequently  than  the  large  heart.  Impure  heart  sounds  are  heard  at  the 
apex  and  slightly  above  that  point  and  soft  systolic  murmurs  are  com- 
mon. The  blood-pressure  is  generally  normal,  but  arterial  tension  is  occasion- 
ally reduced. 

The  total  daily  quantity  and  the  general  appearance  of  the  urine  do 
not  differ  materially  from  the  normal.  That  a  sediment  of  phosphates  and 
urates  may  appear  in  the  several  specimens  collected  for  examination  is  in 
part  due  to  alimentary  causes  and  is  in  part  dependent  upon  increased 
concentration  resulting  from  the  orthosis.  The  marked  cloudiness,  espe- 
cially in  the  morning  specimen  of  urine  in  girls,  at  the  developmental  pe- 
riod, is  a  result  of  the  desquamative  catarrh  of  the  external  genitalia  which 
is  notably  common  at  this  age.  A  sediment  consisting  of  numerous  flat 
epithelial  cells  and  leucocytes  comes  from  the  same  source.  Oxalate 
crystals  are  not  uncommon.  In  a  twenty-four  hour  specimen  of  urine  the 
protein  content  is  often  minimal.  A  clear  understanding  of  the  condition 
may  be  obtained  only  from  the  examination  of  a  succession  of  specimens. 
Urine  excreted  during  the  time  when  the  patient  is  lying  down  is  usually 
free  from  protein  which  reappears  when  the  patient  gets  up.  Since  the 
proteinuria  which  develops  while  the  patient  is  erect  may  at  times  continue 
for  several  hours  after  lying  down,  the  morning  specimen  is  found  free  of 
protein  only  when  that  excreted  during  the  early  hours  of  the  night  is 
separated  from  it  and  when  the  patient  has  not  risen  during  the  remainder  of 
the  night.  The  urine  excreted  during  the  first  few  hours  after  rising  contains 
the  largest  amount  of  protein,  which  increases  with  the  quantity  of  urine 
voided  during  this  period.  Under  ordinary  circumstances  the  curve  repre- 
senting the  protein  content  sinks  gradually  from  a  rapidly  attained  maxi- 
mum to  normal.  Even  in  children  who  have  spent  the  greater  part  of  the  day 
on  their  feet,  the  urine  is  comparatively  free  from  protein  toward  evening. 
If  the  child  lies  down  during  the  day  the  protein  content  of  the  urine  will 
again  increase  after  the  patient  gets  up.  Thus  the  regularity  of  a  cyclic 
albuminuria  is  dependent  upon  the  daily  routine  and  its  apparent  periodi- 
city is  governed  by  external  influences.  Upon  continued  rest  in  bed  the 
urine  of  all  these  patients  is  free  from  protein  and  the  morning  maximum 
can  easily  be  made  to  appear  at  night.  The  longer  the  horizontal  position 
is  continued,  the  greater  is  the  influence  of  the  change  of  posture.  The 
amount  of  protein  in  the  urine  of  the  orthotic  patient  varies  within  wide 
limits  in  the  given  individual  as  well  as  in  different  cases.  Generally 
speaking,  the  amount  of  protein  remains  within  moderate  bounds,  but  may 
run  as  high  as  2-5  parts  per  thousand  and,  in  exceptional  cases,  even  more 


DISEASES  OF  THE  GENITOURINARY  SYSTEM         425 

The  percentage  of  protein  in  the  given  specimen  depends  in  great  measure 
upon  the  dilution  of  the  urine,  excreted  during  the  first  fifteen  minutes  in 
the  erect  posture,  by  that  collected  in  the  bladder  during  the  prone  position. 

In  a  degree  the  excretion  of  a  protein  body  which  can  be  demonstrated 
only  by  coagulation  with  dilute  acetic  acid  in  the  cold  specimen  is  quite 
characteristic  of  functional  albuminuria.  While  this  protein  is  hardly 
ever  absent,  its  proportion  to  the  total  protein  excretion  is  variable.  Occa- 
sionally it  exceeds  other  proteins. 

In  order  that  this  significant  finding  be  not  overlooked  the  test  should 
be  carried  out  as  follows :  The  clear  filtered  urine  is  divided  in  three  test- 
tubes  and  is  diluted  with  two  or  three  parts  of  water.  The  first  tube  is 
used  as  a  control.  To  the  other  two  are  added  a  few  drops  of  dilute  acetic 
acid  and  to  one  of  them  a  few  drops,  also,  of  potassium  ferrocyanidc  solution. 
The  reaction  often  requires  some  time  for  its  completion. 

The  quantity  of  urine  excreted  during  the  periods  of  proteinuria  varies 
directly  with  the  quantity  of  protein  present  and  is  governed  by  the  same 
external  influences,  so  that  the  output  of  protein  always  coincides  with  a 
decrease  in  the  quantity  of  urine  (Fig.  109).  With  the  patient  in  the 
erect  position,  the  urine  is  dark,  contains  much  urobilin  and  bile  salts  but, 
with  exception  of  an  occasional  hyalin  cast,  no  formed  element.  The 
sodium  chloride  content  is  low.  While  in  the  prone  position  the  quantity 
of  the  urine  is  increased  with  resulting  pollakiuria  and  occasional  enuresis. 
It  is  lighter  color,  less  acid  or  even  alkalin.  Zondeck  maintains  that  the 
otherwise  normally  functioning  kidney  is  unable  to  handle  heavy  loads  of 
protein  and  to  be  slow  in  the  excretion  of  sodium  chloride. 

Nature  and  Pathogenesis. — In  spite  of  the  fact  that  for  a  long  time  the  in- 
terest of  the  physician  has  been  especially  directed  to  the  study  of  the  nature 
and  pathogenesis  of  intermittent  proteinuria,  many  important  points  are  still 
unexplained.  The  view  that  cyclic  albuminuria  represents  an  extremely 
insidious  chronic  nephritis,  probably  developing  from  the  first  in  very  small 
foci,  has  lost  much  of  its  support.  The  most  damaging  blow  to  this  theory 
was  recently  given  by  the  actual  findings  of  Heubner  and  Langstein  in  a 
case  at  autopsy.  In  a  ten-year-old  girl  subject  to  orthotic  albuminuria,  and 
dying  of  an  intercurrent  disease,  no  nephritic  changes  were  found.  Why 
the  kidney  functionates  abnormally  and  why  this  abnormal  function  should 
be  induced  by  a  posture,  are  questions  which  still  remain  unanswered.  The 
second  question  seems  nearer  a  solution  than  the  first.  It  has  been  deter- 
mined experimentally  that  the  change  from  the  horizontal  to  the  erect  posi- 
tion is  the  determinating  factor.  But  a  further  qualification  becomes 
necessary.  If  the  body-weight  is  eliminated  by  immersion  in  water,  or  if 
the  body  is  stretched  by  supporting  its  weight  from  the  head,  the  protein- 
uria does  not  appear.  So  that  apart  from  posture,  the  influence  of  the  body- 
weight  upon  the  position  is  evidently  a  factor.  In  the  normally  erect 
position  there  is  a  slight  lordosis  of  the  vertebral  column.  Jehle  has  found 
that  all  his  patients  showed  a  distinct  and  typical  lordosis  of  the  lumbar 
spine  and  he  considers  this  of  etiologic  importance.  In  order  to  affect  the 
urinary  excretion,  the  lordosis  must  be  sharply  curved  with  its  extreme 


426  TEXT-BOOK  OF  PEDIATRICS 

point  at  the  level  of  the  first  or  second  lumbar  vertebra.1  Jehle  believes 
that  such  a  lordosis  distorts  the  renal  vessels  passing  over  its  ventral  con- 
vexity and  thus  hinders  the  circulation  in  the  kidneys. 

There  can  be  no  doubt  that  lordosis  is  an  important  factor  in  the  eti- 
ology of  orthotic  proteinuria;  but  many  more  careful  observations  will  bo 
required  to  determine  the  actual  measure  of  the  part  it  plays.  It  has  been 
definitely  shown  that  the  development  of  a  typical  lordosis  may  provoke 
proteinuria  in  convalescents,  but  a  greater  degree  of'  deformity  is  required 
to  produce  this  effect  in  such  persons  than  is  seen  in  the  spontaneous  lordosis 
of  many  patients  with  orthotic  proteinuria.  Then,  too,  it  is  to  be  remem- 
bered that  typical  lordoses  without  proteinuria  occur.  Further  it  is  to 
be  noted  that  in  the  proteinuria  caused  by  lordosis  in  healthy  children  the 
proportion  of  acetic  acid  test  bodies  in  the  total  protein  is  distinctly  less 
than  in  true  orthotic  cases.  From  this  it  would  not  seem  that  an  orthotic 
proteinuria  could  be  hidden  by  a  lordotic  proteinuria.  It  is  rather  a  question 
how  the  severe  reaction  of  the  orthotic  patient  can  be  explained  by  the 
slight  lordosis. 

The  hypothesis  of  von  Noorden,  Weinstraud  and  others  deserves  some 
attention.  They  suggest  that  the  tonicity  of  the  trunk  muscles  in  the 
erect  position  furnish  a  nervous  impulse  which  in  turn  results  in  a  spasm  of 
the  kidney  vascularity  with  nephritic  ischsemia  and  definite  changes  in  the 
excreted  urine.  This  is  supported  by  the  fact  that  the  urine  secreted  while 
the  patient  is  in  an  upright  position  resembles  that  obtained  by  temporary 
clamping  of  the  kidney  vessels.  The  author  is  inclined  to  suggest  the 
term  " angiospastic  dysuria." 

The  mechanical  factor  of  the  lordosis  apparently  becomes  operative 
when  it  is  present  in  constitutionally  weak  individuals.  Of  the  constitu- 
tional anomaly  which  this  theory  presupposes,  it  may  be  said  that  it  ap- 
pears within  a  definite  period  during  the  years  of  development  and  that 
it  affects  either  the  secretory  or  the  circulatory  apparatus  of  the  kidney. 
It  is  a  well-known  fact  that  the  slightest  disturbance  of  the  blood  supply 
changes  the  kidney  into  a  protein  secreting  organ.  Vasomotor  variations  of 
the  renal  circulation,  dependent  upon  a  constitutional  predisposition  and 
induced  by  a  lordotic  posture,  must  be  regarded  from  the  present  viewpoint 
as  the  etiologic  basis  of  orthotic  proteinuria. 

Diagnosis. — The  diagnosis  of  an  intermittent  proteinuria  determined 
by  posture  is  readily  made.  The  careful  examination  of  specimens  from 
each  urination  for  protein,  and  the  observation  of  the  cardiovascular  and 
nervous  symptoms,  is  all  that  is  necessary.  With  this  initial  determination, 
however,  the  clinical  interest  in  a  case  has  only  begun  and  diagnostic 
difficulties  appear  which  cannot  be  met  by  the  most  careful  analyses  of 
single  urinary  specimens.  For  the  orthotic  type  of  proteinuria  is  not 
specific  since  nephritic  proteinuria  may,  and  not  infrequently  does,  take  on 
the  similar  form.  A  supposed  orthotic  proteinuria,  giving  small  amounts 
of  protein  in  the  morning  specimens,  after  all  precautions  have  been  taken, 

1  Pseudo-lordosis,  in  which  the  spinal  column  is  sharply  bent  backward  directly  over 
the  sacrum,  is  a  very  common  condition  in  childhood. 


DISEASES  OF  THE  GENITOURINARY  SYSTEM         427 

and  in  which,  moreover,  the  cycle  cannot  be  interrupted  by  periods  of  rest 
in  bed  must  always  excite  a  suspicion  of  nephritis.  This  suspicion  increases 
if  the  effects  of  a  nephritic  increase  of  blood-pressure  are  discoverable  in  the 
pulse  and  heart-beat.  The  diagnosis  of  nephritis  is,  of  course,  fully  estab- 
lished when  albuminuric  retinitis,  usually  sought  in  vain,  is  discovered. 
Slight  uremic  symptoms  make  the  differential  diagnosis  no  easier,  since 
they  are  not  unlike  those  which  patients  with  orthotic  proteinuria  exhibit. 
The  slightest  urinary  sediment  should  be  carefully  examined.  It  is  true 
that  one  or  two  hyaline  casts  in  the  sediment  obtained  by  the  use  of  the 
modern  centrifuge  are  not  very  significant.  If,  however,  well  and  regularly 
formed  hyaline  casts  are  found  in  large  numbers,  with  other  varieties  of 
casts  and  red  blood-cells,  we  must  always  consider  them,  according  to 
Heubner,  as  manifestations,  not  of  orthotic  proteinuria,  but  of  nephritis. 
If  these  distinctive  signs  are  not  found  at  once  it  may  be  necessary  to  keep 
an  obscure  case  under  observation  for  months  in  order  to  clear  it  up,  for 
even  hi  true  nephritis  long  periods  may  elapse  in  which  there  is  a  minimal 
amount  of  sediment  with  only  an  occasional  renal  element. 

The  differentiation  of  proteinuria  from  the  normal  status  is  more  simple; 
but  since  its  therapy  is  of  the  passive  order  the  effort  loses  interest.  For 
traces  of  protein  in  the  diurnal  urine  do  not  justify  us  in  pronouncing  a 
child  ill  who  does  not  complain  nor  does  it  demand  the  interference  of  the 
physician.  It  .can  hardly  be  considered  rational  to  place  a  child  in  a 
position  of  forced  lordosis  merely  for  purposes  of  diagnosis,  even  if  it  did 
not  lead  at  tunes  to  harmful  and  mistaken  conclusions.  Especially  is  this 
true  since  so  imminently  a  sensitive  organ  as  the  kidney  may  respond  even  in 
the  healthy  individual  to  such  a  trauma  not  only  by  way  of  proteinuria, 
but  also  by  the  appearance  in  the  urine  of  large  numbers  of  red  blood-cor- 
puscles and  of  hyaline  casts.  From  a  medical  viewpoint  interest  attaches 
only  to  the  question  whether  the  demands  of  the  child's  daily  routine 
cause  proteinuria. 

Prognosis. — The  prognosis  of  pure  orthotic  proteinuria  is  always  favor- 
able and  this  marks  the  practical  distinction  between  the  orthotic  type  and 
all  other  forms  of  proteinuria  which  are  affected  by  posture.  If  a  case  of 
orthotic  proteinuria  terminates  in  chronic  nephritis,  either  an  error  in 
diagnosis  or  a  combination  of  disease  must  be  suspected.  The  latter  is,  of 
course,  possible,  but  there  is  nothing  to  show  that  the  kidney  of  the  orthotic 
patient  is  especially  predisposed  to  inflammatory  changes.  Uncomplicated 
orthotic  proteinuria  usually  runs  a  very  chronic  course.  Recovery  even  in 
the  course  of  one  or  two  years  is  not  common.  Usually  the  earlier  it  appears 
the  longer  it  lasts,  for  spontaneous  recovery,  and  there  is  no  other,  is  com- 
monly postponed  until  after  puberty.  The  condition  hardly  ever  persists 
later  than  the  twentieth  year.  Intermissions,  lasting  for  months,  may  occur. 

Treatment. — The  subjective  disorders  accompanying  the  symptoms  of 
proteinuria  are  more  amenable  to  treatment  than  the  major  symptom  itself. 
Quinine  or,  when  anemia  or  chlorosis  is  present,  iron  is  often  of  great 
service.  Such  procedures  as  prolonged  and  absolute  rest  in  bed,  in  the 
effort  to  suppress  the  excretion  of  protein  at  any  price,  are  contraindicated. 


428  TEXT-BOOK  OF  PEDIATRICS 

The  loss  of  protein  is  never  great  enough  to  endanger  the  metabolism  even 
though  the  amounts  are  seemingly  large.  The  rest-cure  only  delays  the 
achievement  of  the  purpose  of  saner  therapeutic  measures,  the  general 
upbuilding  of  the  body.  For  this  purpose,  exercise  is  more  important  than 
rest ;  and  fresh  air  with  suitable  games  should  be  encouraged  rather  than 
denied.  Dietetic  treatment  must  be  considered  from  the  same  viewpoint. 
The  so-called  nephritic  diet  is  to  be  avoided  and  the  appetite  should  be 
stimulated  by  a  varied  diet  suited  to  the  age  of  the  patient.  It  is  not  neces- 
sary even  to  prohibit  meat  and  eggs.  Gymnastic  exercises  for  the  correction 
of  the  lordosis  and  the  development  of  the  muscles,  especially  of  the  trunk 
and  abdomen,  are  to  be  recommended.  Standing  or  kneeling  for  any  length 
of  time,  tending  to  increase  the  lordosis,  mu?t  be  avoided.  Orthopedic 
correction  of  the  lordosis  does  not  seem  justified.  Low-heeled  shoes  serving 
to  counteract  the  lordosis  may  be  worn. 

TUBULAR  NEPHROPATHY  OR  NEPHROS1S 

Pathology. — A  chronically  progressive  cloudy  swelling  \\ith  hyaline 
deposits,  fatty  deposits  and  with  lipoid  degeneration  or  necrosis  of  the 
tubular  epithelium.  Connective  tissue  and  glomeruli  may  be  affected  in 
the  early  stages  and  always  are  in  the  late  chronic  cases. 

Etiology. — The  etiologic  factor  is  frequently  indeterminable.  Diphtheria, 
lues,  tuberculosis,  or  chronic  purulent  processes  may  be  factors.  Occasion- 
ally the  condition  may  be  brought  on  by  acute  poisoning  with  tar  in  oint- 
ments or  salvarsan— in  rare  cases  the  colon  bacillus  or  pneumococcus  may 
be  the  cause. 

Pathogenesis. — The  knowledge  of  the  pathogenesis  rests  upon  various 
hypotheses,  one  of  which  lays  the  causation  to  the  toxemia  of  the  body  cells 
by  the  products  of  decomposition  of  the  diseased  tubular  epithelium.  It  is 
certain  that  this  disturbance  of  the  secretion  of  the  urine  is  as  definitely  a 
constitutional  disease  as  it  is  a  true  kidney  disease. 

The  functional  disturbance  is  characterized  by  the  reduced  excretion  of 
sodium  chloride  and  water,  during  the  stage  of  edema,  while  there  is  no 
change  in  concentration  power.  With  the  improvement  of  the  condition 
the  excretion  of  these  two  substances  increases  and  may  be  excessive.  There 
is  a  distinct  tendency  to  eclamptic  uremia.  The  excretion  of  nitrogen 
remains  normal  or  may  be  increased  to  as  high  as  2  to  3  per  cent,  in  tho 
twenty-four  hour  specimen  and,  for  this  reason,  there  is  no  nitrogen  reten- 
tion (80-100  mg.  per  100  c.c.  in  protein  free  blood)  and  as  a  result  no  azc- 
temia.  During  the  formation  of  the  edema,  the  blood  is  thickened  and  as 
the  water  is  increased  becomes  thin  again  which  can  be  recognized  by  the 
variation  in  the  red  cell  count. 

Symptomatology. — The  outstanding  feature  of  the  clinical  picture  is  the 
pallor  and  edema.  As  a  result  of  the  edema,  we  have  the  transudates  into 
the  body  cavities,  gastro-intestinal  disturbances,  eclamptic  uremia  and 
generally  lowered  resistance.  The  urine,  in  which  there  is  a  great  deal  of 
protein,  at  first  contains  large  amounts  of  formed  elements,  chiefly  lipoid 
and  fatty  casts.  The  absence  of  blood  and  the  normal  blood-pressure  are  of 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         429 

diagnostic  importance.  The  slight  variations  of  temperature  are  of  no 
significance.  Frequently  the  two  important  symptoms  of  pallor  and  edema 
brought  out  in  the  rather  indefinite  history  of  the  case  suggest  essential 
nephrosis.  Slight  swelling  of  the  face  points  to  the  general  anasarca,  while 
sudden  nausea,  weakness  and  dizziness  indicate  brain  edema.  Diarrhoea 
vomiting  or  bronchitis  may  occur.  After  a  week  or  so  the  urine  shows  a 
large  amount  of  protein.  At  this  stage  the  observer  i?  impressed  with  the 
waxy  pallor  and  examination  reveals  the  edema.  The  heart  rate  and  blood- 
pressure  are  unchanged  or  but  slightly  increased.  The  reflexes  may  be 
increased.  The  patient  feels  bad  and  has  no  appetite.  Complains  of  pain 
on  pressure  especially  over  the  tibia.  The  urine,  dark  brown,  cloudy  and 
acid,  is  highly  concentrated  (1039-1050  specific  gravity).  The  twenty-four 
hour  quantity  is  reduced  to  as  low  as  150  c.c.  Large  amounts  of  urates  are 
deposited  on  standing. 

The  protein  content  is  very  great,  amounts  of  10-20-30  per  cent,  or  even 
higher  may  be  demonstrated.  In  the  centrifugate  are  found  epithelium, 
leucocytes,  large  amounts  of  various  kinds  of  casts  at  first,  and  later  epithe- 
lium and  leucocytes  showing  fatty  degeneration  and  lipoid  bodies.  In  the 
later  stages  the  number  of  casts  is  greatly  reduced.  The  absence  of  red  blood- 
corpuscles,  which  may  be  present  in  an  occasional  specimen,  is  diagnostic. 

Course. — While  an  occasional  mild,  post  infectious  case  may  be 
encountered  in  infants,  the  majority  of  the  cases  have  persisted  for  months 
or  even  years.  With  proper  treatment  the  edema  usually  soon  subsides  but 
following  it  we  have  the  second  or  chronic  stage.  In  this  the  little  patients, 
with  dark  circles  under  their  sunken  eyes  and  often  greatly  emaciated,  look 
sick.  Even  though  they  begin  to  feel  better  as  their  appetites  return  and 
weights  increase,  the  tendency  to  edema  still  persists.  It  may  reappear 
suddenly  at  the  slightest  exceeding  of  the  tolerance  for  sodium  chloride  or 
at  times  even  without  demonstrable  cause.  Such  a  recrudescence  may  even 
change  the  rather  monotonous  chronic  condition  to  the  eclamptic  uremic 
form  with  gastro-mtestinal  disturbance.  The  proteinuria  persists  for  a 
long  time  after  the  formed  elements  have  disappeared.  As  in  the  edema  of 
"flour-feeding  injury,"  the  greatest  danger  lies  in  the  lowered  resistance 
especially  against  pneumococci  (peritonitis,  empyema).  Death  may  result 
from  angina  or  bronchitis  or  erysipelas  from  an  infected  wound. 

Prognosis. — The  prognosis  must  be  guarded  and  must  take  into  consid- 
eration the  chronicity  and  danger  of  infection.  Either  transition  to  a  con- 
tracted kidney  or  eventual  recovery  are  possible.  Recovery  is  complete 
only,  when,  without  proteinuria,  the  excretion  of  10  grams  of  sodium  chlo- 
ride in  twenty-four  hours  can  be  demonstrated. 

Treatment. — The  treatment  must  be  directed  first  against  the  edema. 
During  the  period  of  formation,  however,  not  much  can  be  accomplished. 
Even  when  the  tissues  are  filled  such  medicinal  aids  as  heart  stimulants 
and  diuretics  do  not  drive  the  fluid  into  the  blood  and  to  the  kidney.  At 
times  five  to  ten  grams  of  urea  in  water  may  help  or  a  liberal  venesection 
(100-200  c.c.)  may  be  useful.  The  author  has  seen  the  anuria  overcome 
in  several  cases  by  the  use  of  large  amounts  of  water  (1  litre)  given  as  Vol- 


430 


TEXT-BOOK  OF  PEDIATRICS 


hard  recommends.  The  hunger  and  thirst  cure  of  von  Noorden  and  Volhard 
has  much  to  recommend  it.  This  consists  of  a  diet  of  sufficient  fat  in  form  of 
unsalted  butter  or  cream,  sugar  in  form  of  a  fruit  syrup,  and  a  little  salt- 
free  bread — together  with  as  much  fluid  as  there  was  urine  excreted  on  the 
previous  day.  Breast-milk  may  be  used  even  in  older  children.  Transu- 
dates  and  ascites  may  be  relieved  by  tapping.  The  fluid  obtained  is  milky 
owing  to  the  lipoids.  The  relief  of  the  anasarca  by  scarification  or  by  drain- 
age with  hypodermic  canula  cannot  be  used  in  infants  because  of  the 

danger  of  infection.  Sweats  pro- 
duced by  moist  or  dry  heat  are 
useful.  The  treatment  of  uremia 
has  been  discussed. 

After  the  removal  of  the  fluid 
the  patient  is  usually  hungry  and 
the  diet  should  be  salt-free  and  not 
contain  too  much  liquid,  but  must 
supply  sufficient  calories.  It  must 
be  adjusted  to  the  tolerance  for 
protein,  replacing  that  lost  by  pro- 
teinuria.  Furthermore  in  the  feed- 
ing the  tendency  to  edema  must  be 
considered  and  changes  made  to 
keep  pace  with  the  gradually  in- 
creasing sodium  chloride  tolerance 

^^g|  and  water  excretion.     The  latter 

can  be  determined  by  the  relation 
of  body-weight  and  fluid  intake  and 

***^P9  urine  excreted.    The  determination 

of  the  excretion  of  sodium  chloride 
is  readily  accomplished  with  the 
Strauss  chloridometer,  the  use  of 

*%L ,  which  is  as  simple  as  that  of  the 

Esbach  albuminometer.  To  reca- 
pitulate :  the  diet  should  consist  of 
fat  in  the  form  of  unsalted  butter 
and  cream,  sufficient  protein  (cheese  and  meat),  some  carbohydrate  (bread, 
gruels,  etc.)  and  some  fresh  vegetables  for  the  vitamine  requirement. 

Diphtheritic  nephrosis  presents  all  the  symptoms  of  very  mild  tubular 
disease.  It  is  rare  in  mild  infections  and  common  in  the  severe  forms.  It 
begins  early,  usually  between  the  fourth  and  tenth  days.  The  tendency  to 
edema  is  an  early  symptom  but  the  patients  rarely  present  severe  anasarca 
or  ascites.  Usually  the  retention  of  fluid  is  evidenced  only  by  the  rapid 
increase  in  weight  which  should  lead  to  examination  of  the  urine.  The  total 
daily  quantity  is  decreased  but  rarely  below  200  to  500  c.c.  The  color  is 
dark  yellow  or  dirty  brown.  Protein  and  formed  elements  may  be  present 
in  small  amounts  at  the  beginning  or  entirely  absent  in  the  milder  forms. 
The  protein  rarely  exceeds  1  or  2  per  cent,  with  the  Esbach  method.  The 


FIG.  110 — General  nephritic  dropsy,  ascites  (Uni- 
versity Children's  Hospital,  Munich,  Prof. 
Pfaundler). 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         431 

formed  elements  soon  disappear.  Red  cells  in  the  urine,  and  increased 
blood-pressure  do  not  occur  in  the  pure  forms. 

Usually  tin's  mild  complication  disappears  in  ten  days  to  two  weeks 
without  symptoms  of  uremia  although  it  may  persist  in  varying  degree  of 
severity  to  the  cardiac  death  caused  by  the  diphtheria  itself  (low  blood- 
pressure).  Transitions  to  the  chronic  forms  occur,  and  the  addition  of 
glomerular  symptoms  is  not  uncommon. 

In  ordinary  cases,  treatment  is  not  indicated  for  the  diet  will  usually  be 
such  as  not  to  exceed  the  sodium  chloride  tolerance  of  the  diphther- 
itic kidney.  In  the  severe  forms  the  treatment  is  that  recommended  for 
true  nephrosis. 

ACUTE     DIFFUSE     GLOMERULAR     NEPHROPATHY,      ACUTE 
GLOMERULAR  NEPHRITIS 

Pathology.— At  first,  congestion  rapidly  followed  by  distention;  that  is, 
elongation  and  widening  of  the  glomerular  loops  with  hyperplasia  of  the 
endothelium  and  swollen  capsular  epithelium.  Later,  obliteration  of  the 
capsule  and  scarification  of  the  glomerulus  may  occur.  The  tubules  and 
parenchyma  may  remain  free  or  become  involved  to  a  varying  degree. 

Etiology. — The  most  important  etiologic  factor  is  scarlet  fever.  Angina, 
bronchial  infection,  pulmonary  disease  (pneumonia),  skin  infection  (ery- 
sipelas), pneumococcus  or  staphlococcus  infection  are  frequent  causative 
factors.  Purpura,  lead  poisoning  and  occasionally  the  factors  listed  under 
nephrosis  must  be  kept  in  mind. 

Functional  Disturbances. — The  marked  reduction  of  the  excretion  of 
the  nitrogenous  waste  products  in  the  urine  and  their  simultaneous  increase 
in  the  blood  and  tissues  is  diagnostic  of  glomerular  nephritis.  The  index 
of  this  condition  is  the  increase  of  the  non-protein  nitrogen  above  normal 
limits.  While  the  kidney  still  retains  its  concentration  power  and  excretes 
urine  containing  1.5-2.5  per  cent,  nitrogen  the  blood  is  sufficiently  relieved. 
Large  amounts  of  the  urinary  poisons  are  neutralized  and  made  harmless 
in  the  retained  fluid  of  the  edema  if  this  does  not  affect  the  central  nervous 
system.  When  there  is  no  edema,  in  the  so-called  "dry  cases"  or  in  cases 
with  hypo-  or  even  isotonuria  accompanied  by  oliguria  or  anuria,  uremia 
obtains.  In  the  uncomplicated  cases  the  sodium  chloride  and  water  are 
excreted,  but  in  edemaious  cases  the  action  is  the  same  as  in  the  nephro- 
sis. Increase  in  blood  volume  without  edema  is  a  serious  symptom  of  kid- 
ney insufficiency. 

Symptoms. — The  most  characteristic  symptoms  are  the  urinary  findings: 
blood,  moderate  amounts  of  protein,  with  oliguria  and  possibly  increased 
specific  gravity  or  anuria  with  uremia.  There  is  an  increase  of  the  blood- 
pressure  and  not  uncommonly  a  tendency  to  edema. 

Course. — The  course  of  the  disease  is  protean.  The  glomerular  nephritis 
may  begin  acutely  at  the  very  onset  of  the  causative  disease  or  may  appear 
insidiously  after  two  to  four  weeks.  Any  one  of  the  characteristics,  either 
alone  or  in  combination  with  others,  may  usher  in  the  onset.  In  the  hospital 
the  increase  in  weight  may  at  times  reveal  the  stage  of  the  pre-edema  or 


432  TEXT-BOOK  OF  PEDIATRICS 

attention  called  by  the  increased  blood-pressure.  In  other  cases  the  patient 
is  brought  for  examination  because  of  the  visible  changes  in  the  urine,  such 
as  bloody  urine,  painful  micturition  or  pollakiuria.  In  still  others  the  pallor, 
lassitude,  anorexia,  and  occasional  vomiting  and  diarrhoea  with  thirst  may 
indicate  urea  poisoning. 

In  its  mildest  forms  the  condition  may  be  without  symptoms,  may  or 
may  not  be  accompanied  by  increased  blood-pressure  and  rarely  has  more 
than  the  so-called  "pre-edema."  It  is  discovered  only  when  a  functional 
test  is  made.  Because  of  its  frequency  and  insidiousness  such  tests  should 
be  made  for  several  weeks  after  recovery  from  all  infectious  diseases.  The 
urine,  light  colored  and  but  slightly  cloudy,  at  first  contains  moderate 
amounts  of  protein.  A  few  white  or  red  blood-cells  can  be  found  microscop- 
ically. Later  an  increasing  number  of  casts  of  ah1  forms  but  without  fat, 
are  found.  This  form  is  cured  in  a  few  weeks  without  other  treatment  than 
rest  in  bed. 

In  moderately  severe  forms  the  picture  is  more  distinct.  These  patients 
are  pale,  the  skin  edema  is  localized  in  various  parts  of  the  body;  the  face, 
sternum,  shins,  and  spine  are  most  frequently  the  site.  The  child  is  tired, 
has  no  appetite  but  is  thirsty.  The  urine  is  red  with  a  greenish  iridescence 
or  a  dirty  brown.  The  protein  content  varies  from  3  to  10  per  cent.  The 
twenty-four  hour  quantity  is  markedly  reduced  to  as  low  as  400-600  c.c.  with 
a  proportionate  increase  of  the  specific  gravity.  The  blood-pressure  may  be 
normal  or  but  slightly  increased.  The  pulse,  slowed,  may  be  arythmic. 
The  condition  improves  gradually  in  two  to  three  weeks.  During  convales- 
cence the  blood-cells,  and  especially  the  white  corpuscles,  persist  for  a  long 
time.  In  some  cases  a  condition  resembling  orthotic  proteinuria  with  al- 
bumen and  formed  elements,  brought  on  by  change  of  posture  may  persist. 
More  frequently  such  a  recrudescence  may  be  brought  on  by  exposure  to  cold 
or  by  acute  angina.  While  most  cases  recover  without  further  complications, 
the  danger  of  transition  into  the  chronic  "  pedonephritis "  must  be  kept  in 
mind.  The  contracted  kidney  is  rarely  seen  as  a  sequel.  In  the  treatment, 
the  milk  diet,  formerly  in  general  use,  is  no  longer  considered  necessary. 
The  diet  should  be  largely  vegetable,  supplying  sufficient  protein  for  the 
requirement  of  the  child.  Absolute  rest  in  bed  is  essential. 

The  severe  form  may  be  ' '  dry  "  or  there  may  be  extreme  general  anasarca. 
At  the  very  onset  other  manifestations  may  be  added  to  those  seen  in  the 
milder  grades.  The  most  urgent  of  these  is  pain  in  the  kidney  region 
probably  arising  from  the  tension  of  the  distended  capsule.  The  urine  is 
usually  a  dark  cloudy  brown  and  only  occasionally  bright  blood  red.  At 
first  it  contains  vast  amounts  of  the  formed  elements  already  described. 
These  gradually  become  less  as  the  condition  persists.  The  protein  content 
is  not  greater  than  in  the  milder  cases.  The  total  daily  quantity  is  decreased 
rapidly  to  200  or  even  as  low  as  50  c.c.  But  in  the  severe  cases  the  specific 
gravity  is  not  increased  proportionately.  Anuria  persisting  for  several  days 
is  not  uncommon.  If  there  is  no  edema,  the  danger  of  uremia  is  very  great. 
The  blood-pressure  is  usually  distinctly  increased.  Uremia  may  be  merely 
indicated  or  it  may  appear  suddenly,  full-fledged.  The  more  common 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         433 

eclamptic  form  may  occur  mixed  with  the  azotemic.  The  general  symp- 
toms are  also  variable.  There  may  be  irregular  variations  of  temperature. 
The  pulse-rate  may  vary  in  accordance  with  the  fever  or  may  be  much  lower. 
Arythmia  is  common. 

Uremic  kidney  death  or  cardiac  death  may  occur  suddenly  after  eight 
to  ten  days  or  even  after  a  longer  period. 

Prognosis. — But  even  most  serious  cases  may  recover  in  spite  of  anuria 
and  uremia.  With  proper  treatment  a  favorable  outcome  is  characteristic 
of  the  glomerular  nephritis  of  childhood.  In  such  cases  the  fluid  in  the 
tissues  is  often  drained  off  through  the  kidney,  this  process  is  accompanied  by 
manifestations  of  eclamptic  uremia,  and  as  the  edema  subsides  the  child 
feels  better.  Nevertheless,  the  convalescent  patient  is  subject  to  recurrences 
as  in  the  milder  forms  and  is  sensitive  to  exposure  and  infections.  The 
protein  may  reappear  on  change  of  posture.  Transitions  to  contracted 
kidney  and  pedonephritis  may  take  place. 

Treatment. — -In  the  treatment  absolute  rest  in  bed  is  imperative.  The 
treatment  of  the  edema  is  discussed  under  nephrosis.  The  use  of  urea  as  a 
diuretic  must,  of  course,  be  omitted.  Strophanthus,  digitalis  and  camphor 
are  indicated  for  cardiac  weakness.  The  therapeutic  measures  combating 
uremia  are  discussed  in  the  introductory  part. 

Great  care  must  be  exercised  to  avoid  sudden  chilling.  When  there  is 
but  a  small  amount  of  protein  and  an  occasional  red  blood-cell  in  repeated 
urine  specimens  the  patient  may  be  permitted  to  get  up  unless  there  is  a 
distinct  orthotic  reaction.  Even  in  the  latter  cases  it  is  well  to  permit  a 
slight  amount  of  exertion  and  change  of  posture  as  the  orthotic  proteinuria 
often  disappears  after  two  to  three  days.  Nothing  is  gained  by  too  long  a 
rest  in  bed.  The  patient  becomes  fussy  and  loses  his  appetite.  The  diet 
similar  to  that  suggested  in  nephrosis  should  be  prescribed  with  the  tend- 
ency to  edema  and  danger  of  overloading  with  protein  constantly  in  mind. 
In  hospitals  the  food  should  be  controlled  by  metabolism  tests  including 
the  determination  of  non-protein  nitrogen  in  the  blood.  The  protein  of  the 
diet  should  be  kept  very  low  if  the  non-protein  nitrogen  is  greater  than 
100  milligrams.  In  the  home,  however,  it  is  generally  necessary  to  be 
guided  by  the  general  condition  of  the  patient  and  the  amount  of  urinary 
sediment  which  very  often  gives  a  very  accurate  index  of  the  nitrogen  metab- 
olism. During  the  first  few  days  a  purely  carbohydrate  diet  is  indicated. 
Later  milk,  which  contains  about  34  grams  protein  per  litre,  may  be  added  in 
increasing  amounts.  It  may  be  given  in  cocoa  or  Keller's  malt  soup. 
Breast-milk  may  be  useful  even  in  older  children.  Broth  should  be  omitted 
because  of  the  sale.  Gradually  light  and  dark  meat  and  even  eggs?  may  be 
added.  In  other  words  the  diet,  in  a  general  way,  should  consist  of  cereals, 
vegetables,  fruit,  and  fat  (unsalted  butter).  The  total  amount  of  liquid 
offered  per  day  should  be  the  same  as  the  amount  of  urine  excreted  the 
previous  day.  After  the  free  excretion  of  urine  has  been  established  the 
patient  may  be  given  as  much  fluid  as  he  will  take. 

Scarletinal  nephritis  is  by  far  the  most  common  form  of  glomerular 
nephritis,  although  a  pure  form  of  septic  interstitial  focal  nephritis  also 
28 


434  TEXT-BOOK  OF  PEDIATRICS 

occurs  with  scarlet  fever.  The  frequency  of  nephritis  with  this  disease 
varies  within  wide  limits  depending  upon  the  nature  of  the  epidemic.  Fur- 
thermore, there  is  doubtless  a  "distinct  familial  predisposition.  Excepting 
for  an  occasional  transitory,  febrile  or  a  more  persistent  hemorrhagic 
(interstitial)  proteinuria,  true  nephritis  does  not  appear  before  the  end  of 
the  second  or  more  commonly  during  the  third  week,  during  the  so-called 
"second  scarlet  fever"  or  during  later  relapses. 

It  is  not  known  whether  this  delayed  kidney  injury  is  to  be  laid  to 
toxins  in  the  form  of  waste  products  of  the  mechanism  of  defense  formed 
gradually  during  the  recovery  from  the  infection,  as  is  suggested  by  von 
Pirquet,  or  whether  it  is  due  to  the  actions  of  the  toxins  of  the  recurring 
attacks  of  the  disease  itself,  according  to  Pospischill  and  Weiss. 

There  is  no  relation  between  the  severity  of  the  primary  disease  and  the 
frequency  of  the  kidney  disease.  It  is  the  experience  of  most  men,  however, 
that  after  cases  of  scarlet  fever  without  eruption  or  with  very  slight  erup- 
tion the  tendency  to  kidney  complication  is  greater.  The  post  scarletinal 
nephritis  may  appear  unexpectedly.  At  times  it  may  be  preceded  by  a 
slight  rise  of  temperature  or  the  temperature  of  the  exanthem  does  not 
become  normal.  After  the  nephritis  has  set  in  there  is  moderate  fever  or 
irregular  variation  of  the  temperature  curve.  This  rise  may  discontinue  in  a 
few  days  or  with  recurrence  persist  for  weeks.  There  is  some  question 
whether  this  fever  is  due  entirely  to  the  kidney  condition.  Usually  there  is 
a  tendency  to  cervical  lymphadenitis  which  usually  manifests  itself  acutely 
before  the  kidney  condition  appears. 

The  symptomatology,  treatment,  and  prognosis  of  scarletinal  nephritis 
are  identical  with  those  of  glomerular  nephritis  in  general.  No  especial 
prophylactic  measures  are  known.  The  old  practice  of  exclusive  milk 
diet  is  objectionable.  Pospischill  has  demonstrated  its  worthlessness  in  a 
large  series  of  cases  in  which  he  gave  milk  to  part  and  general  diet  to  an 
equal  number.  The  effect  upon  the  general  well-being  of  the  patient  is  not 
good.  Some  authors  advise  keeping  the  patient  in  bed  for  several  weeks 
after  convalescence  but  this  also  seems  a  rather  harsh  treatment  of  doubtful 
benefit.  Absolute  rest  in  bed  is  indicated  only  when  there  is  fever  or  when 
leucocytes  or  other  formed  elements  are  found  in  the  urine  or  when  there  is 
danger  of  exposure  to  cold.  In  other  cases  the  patient  is  allowed  to  get  up 
as  soon  as  the  temperature  remains  normal  for  a  few  days. 

GLOMERULO-TUBULAR  NEPHROPATHY  (MIXED  FORM) 

Just  as  glomerulitis  may  occur  with  nephrosis  so  we  may  have  the 
tubular  nephropathy  with  glomerular  affection.  In  such  cases  the  nephrosis 
may  begin  with  the  hematuria  and  increased  blood-pressure  of  a  glomerular 
process  or  both  forms  may  alternate  throughout  the  course  and  influence 
the  entire  disease-picture. 

The  pathologic  findings  show  both  forms  of  lesions  without  the  definite 
differentiation  seen  in  the  individual  diseases  and  without  the  typical 
clinical  course.  The  interstitial  tissue  shows  round  cell  infiltration  and  the 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         435 

interstitial  cells  as  well  as  the  vessel  walls  show  fatty  degeneration.  Scarifi- 
cation of  the  glomeruli  and  even  contracted  kidney  may  result. 

Etiology. — Glomerulo-tubular  nephropathy  is  the  typical  kidney  disease 
of  exudative  children  and  especially  of  infants.  It  is  the  common  sequence 
in  cases  of  impetiginous  eczema  and  otitis  or  may  follow  all  of  the  condi- 
tions causing  glomerulitis  or  nephrosis.  It  rarely  follows  angina,  scarlet 
fever  or  diphtheria. 

Functional  tests  and  blood  chemistry  reveal  reduction  in  the  amount  of 
water,  chlorine  and  nitrogen  excreted.  Hypouria  may  occur.  The  degree 
in  which  each  of  these  functions  may  be  affected  varies  not  only  in  different 
cases  but  also  in  the  course  of  each  case.  In  the  individual  case  there  is  also 
a  certain  relationship  between  the  protein,  sodium  chloride  and  even  water 
retention  so  that  for  instance  an  increase  of  the  sodium  chloride  intake 
may  disturb  the  protein  function  and  vice  versa. 

Symptoms. — The  disease-picture  is,  naturally,  not  uniform.  Usually 
the  condition  is  very  serious  at  first.  In  many  cases  severe  general  anasarca 
is  the  first  symptom.  The  extremely  pale  waxy  face  is  so  swollen  that  the 
little  patient  can  hardly  open  his  eyes.  Frequently  the  distended  skin 
areas  become  the  seat  of  impetigo  with  inflammation  of  the  regional  IjTnph 
nodes  and  fever.  The  patient  lies  very  quiet  and  gives  every  indication  of 
being  extremely  ill.  Vomiting  may  occur  and  diarrhoea  is  common.  The 
blood-pressure  is  increased.  Difficulty  is  experienced  in  producing  perspi- 
ration by  the  use  of  hot  packs  or  pilocarpin  even  in  rickitic  infants.  The 
characteristics  of  the  urine  are  those  described  under  glomerular  nephritis. 
The  persistence  and  obstinacy  of  the  general  edema  is  very  significant.  It 
may  persist  for  weeks  but  usually  passes  off  with  polyuria.  After  its  disap- 
pearance the  patients  often  look  as  atrophic  as  those  recovering  from  the 
"flour-feeding  injury."  During  the  long  drawnout  sickness  the  symptoms 
of  uremia  may  appear  at  any  time.  Very  often  there  is  an  indication  of  it 
in  the  diarrhoea,  vomiting,  headache  and  Babinski  's  phenomenon,  when  the 
edema  begins  to  go  down.  Similarly  the  other  manifestations  encountered 
in  the  convalescent  stage  of  nephrosis  or  glomerular  nephritis  such  as 
orthotic  albuminuria,  recurrences  on  exposure  to  cold,  and  reduction  of 
immunity  are  seen. 

Prognosis. — In  spite  of  the  severity  of  the  disease  complete  recovery 
seems  much  more  common  in  children  than  in  adults.  Nevertheless,  it 
must  be  remembered  that  we  can  speak  of  complete  recovery  only  when, 
after  the  urine  is  free  from  protein  and  formed  elements  including  white 
and  red  blood-corpuscles,  the  metabolism  takes  care  of  the  full  required 
amount  of  sodium  chloride,  protein,  and  water  without  producing  disturb- 
ances of  secretion.  Some  children  die  of  later  complicating  infections  or 
uremia.  A  small  portion  may  have  a  contracted  kidney  or  continue  as 
cases  of  chronic  or  pedonephritis. 

Treatment. — Apparently,  treatment  is  somewhat  more  efficacious  than 
in  adults.  At  least  I  have  thought  that  the  straight  sugar  feeding  recom- 
mended by  von  Noorden  is  of  benefit,  not  only  in  the  acute  nephrosis',  but 
also  as  an  ameliorating  influence  upon  the  glomerular  symptoms.  It  is 


436  TEXT-BOOK  OF  PEDIATRICS 

quite  possible  to  feed  a  three-year-old  child  very  satisfactorily  on  250  grams 
of  glucose  in  fruit  juice  per  day  and  this  may  be  continued  for  ten  days  or 
more.  In  some  cases  diuretics  are  valuable.  During  convalescence  breast- 
milk  is  ideal  even  for  older  children  for  its  sodium  chloride  and  protein 
content  is  low  and  thus  reduces  the  tendency  to  edema.  It  may  be  given  as 
a  major  part  of  the  diet  with  vegetables  and  fruit  until  such  time  when 
the  kidney  can  stand  the  addition  of  protein  and  sodium  chloride.  The 
particulars  of  the  treatment  should  be  regulated  by  the  suggestions  given 
under  nephrosis  and  glomerulitis. 

KIDNEY  DISEASES  IN  INFANTS 

All  of  the  various  conditions  described  above,  except  contracted  kidney, 
occasionally  occur  in  infants.  The  nephritis  frequently  encountered  in  the 
course  of  parenteral  or  enteric  disturbances  of  nutrition  especially  in  intoxi- 
cation and  decomposition  is  of  special  interest. 

The  pathologic  findings  are  not  definite.  There  may  be  no  lesion  or 
only  a  slight  fatty  degeneration  as  in  nephrosis.  In  other  cases  this  fatty 
degeneration  may  be  accompanied  by  foci  of  round  cell  infiltration  in  the 
intestinal  connective  tissue  indicating  a  septic  interstitial  nephrcpathy. 
Clinically,  the  most  important  manifestation  is  the  slight  amount  of  protein, 
which  may,  indeed,  be  lacking  throughout.  It  is  accompanied  by  varying 
amounts  of  hyalin  and  granular  casts,  kidney  epithelial  cells  and  occasional 
leucocytes  and  red  blood-corpuscles.  Edema  is  rarely  present  although  the 
face  or  hands  and  feet  may  at  times  seem  slightly  swollen.  The  sudden  rise 
in  the  weight  curve,  very  significant  in  infants,  is  also  uncommon.  The  con- 
dition agrees  most  closcty  with  the  description  of  a  septic  interstitial  nephro- 
pathy.  Those  cases  in  which  there  is  no  blood  in  the  urine  are  probably  very 
mild  tubular  nephroses.  The  classification  of  the  remainder  of  the  cases  in 
which  there  is  no  pathologic  lesion  in  the  kidney  must  be  left  to  further  study. 

The  pathogenesis  may  be  due  in  part  to  toxins  resulting  from  infection 
or  in  part  to  poisons  arising  in  the  intermediate  metabolic  changes  (acids?). 
Furthermore,  the  infantile  kidney  is  very  easily  injured.  Usually  prompt 
recovery  takes  place  but  the  kidney  disease  may  persist  for  weeks  after  the 
disappearance  of  the  causative  injury.  It  is  probable  that  some  of  the 
cases,  especially  the  infectious  interstitial  nephritis,  may  go  on  as  a  form  of 
chronic  pedonephritis  of  Heubner.  In  the  differential  diagnosis  the  tran- 
sient kidney  irritation  following  alimentary  intoxication,  the  edema  and 
scleredema  of  the  newly  born  and  debilitated  infants  may  be  excluded  by 
consideration  of  the  general  clinical  picture.  The  edematous  form  of 
"flour-feeding  injury''  may  be  ruled  out  by  the  history  and  the  absence  of 
urinary  changes.  The  treatment  of  these  forms  of  kidney  disease  must  be 
dependent  on  the  cause.  Typical  cases  require  the  same  treatment  described 
above.  Breast-milk  is  especially  effective. 

CHRONIC  KIDNEY  DISEASE 

Chronic  nephritis  may  occur  in  childhood  in  the  same  forms  as  it  does  in 
the  adult.  Both  the  large  white  kidney  and  the  contracted  kidney  have 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         437 

been  observed  in  children.  Both  disease-pictures  are  extremely  uncommon 
in  the  first  years  of  childhood.  Their  frequency  increases  toward  puberty. 
Their  clinical  and  structural  features  do  not  differ  essentially  from  the 
chronic  nephritis  of  later  life  and  therefore  they  require  no  further  descrip- 
tion here.  The  only  significant  thing  about  the  chronic  nephritis  of  child- 
hood is  the  rarity  with  which  its  typical  forms  appear.  This  may  be  due  in 
part  to  the  fact  that  certain  etiologic  factors  operative  in  the  adult,  e.  g.,  gout 
arteriosclerosis,  chronic  intoxications,  etc.,  play  no  part  in  the  diseases  of 
childhood.  But  even  where  chronic  nephritis  develops  from  the  acute 
type  which  follows  upon  infections,  its  manner  of  appearance  differs  as 
between  children  and  adults.  In  view  of  these  facts,  a  distinct  advance  was 
made  when  Heubner  defined  the  chronic  nephritis  most  common  in  child- 
hood by  the  term  pedonephritis. 

CHRONIC  NEPHRITIS  OF  CHILDHOOD  (PEDONEPHRITIS) 

This  disease  is  not  uncommon  in  children  between  the  second  and  the 
fourth  years,  but  is  most  frequent  during  school  age.  In  spite  of  its  obsti- 
nacy its  benign  character  is  its  essential  and  significant  trait.  Its  benignity 
is  illustrated  not  only  in  the  mildness  of  its  subjective  symptoms  and  in  its 
not  infrequently  favorable  termination  but  also  in  the  rarity  with  which 
its  course  is  aggravated  by  severe  complications.  Uremia,  retinitis,  serious 
changes  in  the  vascular  mechanism,  or  even  marked  edema  are  seen  only  in 
exceptional  cases. 

Etiology. — It  is  certain  that  pedonephritis  occurs  most  commonly  in 
the  wake  of  acute  infectious  diseases  and  especially  of  scarlet  fever;  yet, 
it  is  not  always  possible  to  trace  its  early  manifestations  to  their  origin 
and  often  its  genesis  remains  obscure. 

This  etiologic  difficulty  is  increased  by  the  fact  that  its  subjective  symp- 
toms as  a  rule  are  so  slight  that  urinalysis  is  not  suggested.  The  patient  is 
pale  and  flabby;  tires  easily;  is  more  or  less  fretful,  but  is  usually  fairly 
well  nourished.  Occasionally  the  child  complains  of  headache,  pain  in  the 
side,  palpitation,  anorexia,  and  thirst ;  but  more  often  its  general  well-being 
is  but  slightly  disturbed. 

Symptoms. — Marked  dropsical  conditions  are  never  seen.  At  the  most 
only  a  slight  fulness  of  the  face  may  be  observed  from  time  to  time. 
Changes  in  the  heart  and  the  pulse  are  neither  frequent  enough  nor  distinct 
enough  to  support  a  diagnosis,  which  must  depend  almost  entirely  upon 
the  urinalysis. 

The  quantity  of  urine  and  its  specific  gravity  remain  fairly  normal  and 
there  is  but  little  cloudiness  and  a  small  amount  of  sediment.  The  propor- 
tion of  protein  is  never  very  high,  usually  varying  between  0.5-2.  per  thou- 
sand. The  proteinuria  may  disappear  at  times  and  at  others  may  assume  the 
orthotic  form.  Structural  elements  are  hardly  ever  lacking  even  in  the 
protein-free  urine.  The  findings  may  be  limited  for  months  to  a  few  red 
blood-cells  and  an  occasional  cast.  Sometimes  hyaline,  granular  and 
epithelial  casts,  with  leucocytes,  are  found  in  large  numbers.  Then  again, 
acute  exacerbations  may  result  in  microscopically  bloody  urine. 


438  TEXT-BOOK  OF  PEDIATRICS 

Generally  speaking,  however,  the  course  is  uneventful.  For  a  long  time 
the  affected  child  might  be  considered  normal  if  it  were  not  for  the  urinary 
findings.  These  with  other  symptoms  of  the  disease  may  gradually  disap- 
pear after,  they  have  persisted  for  years  and  a  lasting  recovery  may  be 
achieved.  A  certain  part  of  these  cases  do  not  recover  during  childhood. 
In  still  others,  the  transition  to  a  contracted  kidney  occurs  sooner  or  later 
with  a  resulting  aggravation  of  symptoms.  Since  it  is  never  possible  to 
predict  how  the  disease  is  going  to  terminate  the  prognosis  must  always  be 
guarded.  The  differential  diagnosis  from  orthotic  proteinuria  has  been 
discussed  under  that  disease. 

Regarding  the  pathologic  changes  occurring  in  pedonephritis,  prece- 
dent to  the  transitions  into  the  contracted  kidney,  very  little  is  known. 
It  is  probably  a  matter  of  small  diffuse  inflammatory  foci  in  the  renal 
parenchyma. 

Treatment. — Treatment  is  not  very  affective  and  hence  care  should  be 
taken  not  to  do  any  injury  by  therapeutic  measures.  Rest  in  bed  with 
restricted  diet  may  be  ordered  to  initiate  treatment  and  to  permit  observa- 
tion. But  the  symptoms  of  disease  will  outlast  rest-cures  and  dietetic  meas- 
ures continued  for  months,  while  the  general  condition  of  the  child  and  its 
measure  of  resistance  will  suffer  in  every  way  from  the  pursuit  of  such 
methods.  Nor  is  the  psychic  injury  of  this  sort  of  treatment  to  be  under- 
estimated. The  general  daily  routine  of  the  patient  should  not  be  inter- 
fered with  any  more  than  is  absolutely  necessary,  in  order  that  his  attention 
may  not  be  too  closely  fixed  upon  his  illness.  Play  and  moderate  physical 
exercise  should  be  permitted.  A  mixed  dietaiy,  including  even  meat,  is  to 
be  recommended.  A  trial  of  a  salt-free  diet  extending  over  a  period  of 
several  weeks  is  justified.  The  use  of  alcohol  or  of  strong  spices,  indulgence 
in  severe  bodily  exercise  and  the  employment  of  cold  baths  must  be  prohib- 
ited. Proper  hygiene  of  the  skin  should  be  secured  by  warm  baths  and 
relatively  warm  clothing.  A  steady  warm  dry  climate,  and  especially  the 
desert  climate  of  Egypt,  seems  to  have  a  beneficial  influence.  Sun-baths 
may  serve  as  a  partial  substitute.  Karslbad  and  other  similar  resorts  have 
also  been  recommended. 

NEPHRITIS  WITH  CONGENITAL  SYPHILIS 

In  the  postmortem  examination  of  congenitally  syphilitic  children 
renal  changes  are  very  commonly  encountered.  Probably  they  are  never 
absent  in  the  syphilitic  fetus  or  new-born.  With  increasing  age  they 
are  more  uncommon  and  less  important.  Apart  from  some  signs  of  degen- 
eration in  the  parenchyma,  these  are  of  slight  degree  and  characteristically 
involve  the  connective  tissue  framework  of  the  organ  and  especially  an 
increase  of  the  cellular  elements  of  the  adventitia  of  the  vessels.  The  forma- 
tion of  small  cysts,  and  such  indications  of  retarded  development  as  the 
prolonged  persistence  of  the  neogenic  cortical  zone,  and  a  diminution  of  the 
number  and  size  of  the  glomeruli  are  remarkably  frequent,  but  not  charac- 
teristic features.  Compared  with  the  general  pathologic  findings  in  such 
cases,  these  changes  are  usually  rather  unimportant,  as  is  equally  true  of  the 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         439 

clinical  manifestations  produced  by  them.  In  occasional,  but  certainly 
very  rare  cases,  hemorrhagic  nephritides  of  luetic  Origin,  resembling  those 
of  the  adult,  are  said  to  have  appeared.  The  frequent  but  usually  slight 
proteinuria  with  but  little  organized  sediment,  is  completely  overshadowed 
by  the  other  symptoms  of  the  luetic  disease.  Edema,  uremia  and  other 
serious  complications  play  no  part. 

Untreated,  the  urinary  changes  may  persist  for  a  considerable  time, 
but  under  specific  treatment  they  usually  disappear  with  other  symptoms. 
The  question  whether  mercury  is  not  at  times  an  etiologic  factor,  rather 
than  a  therapeutic  benefit  must  be  considered. 


CYSTOPYELITIS,  PYELONEPHRITIS  AND  RENAL  ABSCESSES 
Pathologic  conditions  in  the  urinary  organs,  the  common  indication  of 
which  is  the  passage  of  urine  containing  pus,  are  not  uncommon  in  childhood. 
The  fact  that  these  conditions  have  failed  of  the  attention  due  their  great 
importance  can  only  be  attributed  to  the  alleged  difficulties  of  obtaining  a 
urinary  specimen  from  the  young  child.  Even  in  doubtful  febrile  cases  this 
all  important  diagnostic  aid  has  been  neglected.  Since  1894  when  Escherich 
called  attention  to  the  fact,  we  know  that  cystitis  and  other  related  inflam- 
matory diseases  of  the  urinary  tract  are  peculiarly  common  in  early  child- 
hood. The  disorder  is  most  frequently  met  with  during  the  first  year. 
Toward  the  close  of  the  first  six  months  it  rapidly  approaches  its  greatest 
frequency.  It  is  not  uncommon,  however,  in  the  second  year,  but  after  that 
age  it  again  shows  a  gradual  decrease  of  occurrence  with  advancing  age. 
It  is  peculiar  in  the  fact  that  it  appears  more  often  in  girls  than  in  boys. 
Nevertheless,  its  frequency  in  the  male  sex,  representing  about  one-fourth 
of  all  cases,  is  not  to  be  underestimated. 

The  early  observers  of  purulent  urine  in  young  children  diagnosed  cystitis, 
but  later  authors  have  called  attention  to  the  frequent  extension  of  the  disease 
to  the  pelvis  of  the  kidney.  As  in  the  respiratory  and  digestive  tracts,  so  in 
the  urinary  passages,  inflammatory  conditions  are  rarely  confined  to  any  dis- 
tinct anatomic  division.  One  part  after  another  of  the  urinary  tract  may 
show  well-developed  structural  changes,  and  yet  diagnostically  it  is  dif- 
ficult to  differentiate  a  catarrhal  affection  of  the  lower  urinary  tract  from 
that  of  the  upper.  The  extension  of  the  disease  to  the  calices  of  the  kidney 
or  to  the  renal  tubules  may  give  symptoms  that  make  possible  a  differential 
diagnosis.  So  that  cystitis,  pyelitis,  pyelocystitis  and  pyelonephritis  may 
be  essentially  but  different  stages  of  one  and  the  same  process. 

The  findings  at  autopsy  are  often  in  sharp  contrast  with  the  clinical 
symptoms  and  especially  with  the  urinary  changes.  In  spite  of  a  well 
established  pyuria,  but  slight  changes  in  the  mucosa  are  found.  In  mild 
cases,  these  consist  simply  of  a  circumscribed  hyperemia  and  a  slight  swell- 
ing of  the  mucosa.  In  one  instance  these  manifestations  may  be  more 
marked  in  the  pelvis  and  in  another  in  the  bladder.  In  severe  forms  the 
structural  changes  are  more  distinct  and,  in  addition  to  thope  already  cited, 


440  TEXT-BOOK  OF  PEDIATRICS 

submucous  hemorrhages,  more  or  less  extensive  ulcerations  and,  more 
rarely,  -wide-spread  fibrino- purulent  exudafces  appear.  If  the  kidney  is  also 
involved  it  is  enlarged,  cloudy  and  soft.  Dark  red  hyperernic  spots  and 
yellowish  areas  containing  pus  give  a  mottled  appearance  to  the  surface 
and  on  section.  Occasionally  the  purulent  infiltration  is  confined  to  the 
papillae  or  the  calices,  or  it  may  spread  in  a  wedge-like  form  toward  the 
cortex.  In  a  word,  the  condition  is  one  of  ascending  infection. 

A  variety  of  organisms  may  be  responsible  for  the  appearance  of  pus 
in  the  urinary  tract.  Practically,  cystopyelitis  due  to  the  colon  bacillus 
takes  the  first  and  most  important  place.  In  the  majority  of  cases  this 
organism  is  found  in  pure  culture.  Staphylococci,  streptococci  and  gono- 
cocci  are  found  with  the  colon  bacillus  or  alone.  The  tubercle  bacillus  is 
seldom  a  cause  of  the  disease. 

The  invasion  of  the  urinary  tract  by  micro-organisms  does  not  neces- 
sarily invoke  disease.  According  to  Langer  and  Soldin  the  streptococcus 
lacticus  is  a  normal  inhabitant  of  the  urinary  organs  during  infancy.  The 
work  of  Kleinschmidt,  Helmholtz  and  Miliken,  however,  tends  to  show  that 
this  organism  is  a  contamination  and  even  though  found  in  the  catheterized 
specimen  does  not  necessarily  have  to  get  into  the  urine  by  way  of  the  blood. 
The  results  of  infection  develop  only  when  the  factors  of  predisposition  are 
present.  This  predicates,  first  of  all,  a  marked  decrease  of  the  general 
resistance  to  infection  as  the  result,  for  instance,  of  severe  exudative 
diathesis.  In  such  cases,  and  still  more  commonly  in  severe  acute  gastro- 
intestinal diseases,  the  infection  of  the  urinary  tract  occurs  as  soon  as  the 
loss  of  strength  has  reached  a  certain  ebb  and  often  while  the  patient 
is  still  under  observation  for  the  primary  malady.  In  consequence  the 
prognosis  becomes  much  more  serious. 

Besides  these  general  predisposing  influences,  the  mere  diminution  of 
the  quantity  of  the  urine,  the  consequent  loss  of  the  continuing  flush  of 
waste  material  from  within  outward  and  the  retention  of  small  portions  of 
the  urine  in  the  bladder,  are  circumstances  which  pave  the  wa y  for  infection. 
Dilatations  or  constrictions  of  the  ureters  or  any  actual  malformation  of 
the  geni to-urinary  organs  may  induce  similar  results.  The  writer  has  seen 
several  cases  in  which  symptoms  of  inflammation  followed  the  excretion  of 
urine  containing  large  deposits  of  uric  acid  crystals  and  urates. 

Pathogenesis. — We  do  not  know  how  the  bacteria  reach  the  affected 
area  in  each  and  every  case.  This  is  entirely  clear  only  when  cystitis  follows 
the  practice  of  catheterization.  There  is  no  doubt  that  the  infection  may 
pass  from  without  inward.  The  question  whether  the  tract  is  traversed  in 
this  manner  in  the  majority  of  cases  cannot  be  definitely  determined, 
despite  the  fact  that  a  large  number  of  these  cases  occur  in  females,  in 
whom  the  urethra  is  shorter  and  more  direct.  It-  is  generally  denied  so  far 
as  the  male  is  concerned.  This  suggests  a  different  etiology  in  the  two  sexes. 

On  the  other  hand,  the  infection  is  often  believed  to  be  hematogenous. 
Since  the  presence  of  various  micro-organisms  in  the  urine  is  not  unusual 
and  since  bacteria,  and  especially  colon  bacilli,  have  been  found  in  the  cir- 
culating blood  of  infants  suffering  with  intestinal  diseases,  the  hemato- 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         441 

genous  origin  of  the  disease  seems  well  supported.  The  theory  of  direct 
migration  OL  the  bacilli  from  the  colon  to  the  bladder  appears  less  probable; 
experimentally,  at  least,  it  requires  extensive  lesions  of  the  intestinal  mu- 
cosa.  Too  little  attention  has  been  given  to  a  fourth  possibility,  viz.: 
infection  by  the  lymph  channels,  unquestionably  the  paths  best  adapted 
to  bacterial  transmission.  Lymph  vessels  draining  the  region  of  the  ascend- 
ing colon  and  the  appendix  and  communicative  with  the  lymph  channels 
of  the  parenchyma  of  the  kidney  have  been  demonstrated.  That  these 
channels  are  actually  less  complete  or  even  entirely  absent  on  the  left  side 
may  account  for  the  greater  frequency  of  pyelitis  on  the  right. 

Clinical  Course. — When  pyelocystitis  appears  in  the  course  of  some 
preexisting  disease  its  particular  manifestations  may  be  lost  in  the  symp- 
tom picture  of  the  primary  disorder.  A  relapse  during  convalescence,  or 
even  an  unaccountable  rise  in  temperature  may  indicate  the  development 
of  some  complication. 

Even  in  the  event  of  an  apparently  primary,  idiopathic  pyelocystitis 
the  characteristic  symptoms  of  the  disease  are  often  absent.  Cases  are  seen 
in  infants  in  which  there  is  no  fever  or  only  a  slight  rise  of  temperature.  The 
first  intimation  of  the  condition  is  given  by  the  examination  of  the  urine.  In 
older  children  there  may  be  some  difficulty  of  micturition.  They  suffer 
severely  and,  crying  or  screaming  with  pain,  evacuate  small  amounts  of 
urine  at  short  intervals.  As  a  result,  many  a  child  will  refuse  to  go  to  stool 
and  will  soil  its  clothing  although  it  has  previously  acquired  habits  of 
cleanliness.  During  micturition  the  patient  draws  up  his  legs,  or  presses 
his  hands  over  the  bladder  region.  These  symptoms  are  rare  in  infants. 
Tenderness  or  pressure  may  be  elicited  over  the  kidney  and  bladder  region 
in  a  few  cases.  The  diagnosis  of  a  supposedly  enlarged  kidney  is  due  to 
the  failure  to  recognize  the  physiologic  low  position  of  the  child's  kidney 
and  to  the  increased  sensitiveness  to  pressure.  After  the  second  year,  the 
more  severe  forms  of  the  disease  are  uncommon.  After  this  period  the 
disorder  may  set  in  almost  unobserved  and  may  show,  from  the  very  first,  a 
more  chronic  tendency. 

Acute  primary 'cystitis  follows  a  more  severe  course  in  infancy.  It 
presents  the  picture  of  a  serious  infectious  disease.  The  child  becomes  rest- 
less and  fussy  and  the  temperature  rises  rapidly  to  39°-40°  C.  (102°-104:> 
F.),  or  more.  The  fever  may  be  accompanied  by  convulsions.  The  pulse 
and  respiration  become  rapid.  Vomiting  during  the  first  few  days  is  com- 
mon. Even  though  consciousness  may  not  be  impaired  the  child  gives  one 
the  impression  of  being  seriously  ill.  It  is  extremely  cross  and  irritable; 
cries  and  often  shrieks  upon  the  approach  of  anyone  and  objects  strenuously 
to  being  moved.  A  more  serious  condition  may  follow  or  persist  from  the 
onset  indicating  the  involvement  of  the  pelvis  or  even  the  kidney  itself. 
Because  of  the  extreme  thirst  the  child  grasps  the  bottle  greedily,  only  to 
push  it  away  after  taking  a  few  swallows.  The  loss  of  strength,  hastened  by 
the  anorexia  and  the  refusal  of  food,  soon  becomes  noticeable.  The  initial 
period  of  irritability  is  followed  by  depression.  The  little  patient  lies 
absolutely  still,  save  for  the  rapid  respiration  and  for  occasional  slow  groping 


i;  -> 


E; 


m 


motions  of  the  hands;  the  face  is  contorted  with  pain 
and  anguish;  the  eyes  are  wide  open  and  bright. 

Even  in  the  breast-fed  infant  the  digestive  func- 
tions, as  indicated  by  the  consistency  of  the  stools, 
are  almost  always  affected.  It  sometimes  happens 
that  the  picture  of  a  severe  acute  nutritional  disturb- 
ance, with  typical  signs  of  intoxication,  is  secondarily 
induced  by  the  parenteral  infection.  Toward  the  end 
of  the  first  week's  illness,  an  almost  characteristic 
yellowish  pallor,  together  with  an  increasing  flaccidity 
of  the  skin,  becomes  apparent.  The  abdomen  is 
sunken  and  the  skin  loses  its  elasticity.  If  the 
irritation  and  pain  is  extreme  a  reflex  muscular  spasm 
of  the  back  occurs  and  opisthotonus  and  other  signs 
of  meningitis  are  presented.  If  this  irritation  is  more 
marked  on  the  right  side,  the  condition  may  simulate 
a  perityphelitis. 

Course  and  Termination. — Though  the  disease 
runs  along  writh  high  fever  and  extreme  illness  with 
very  gradual  remissions  and  slow  improvement,  fatal 
termination  is  uncommon.  But  the  patient  may  die 
after  weeks  of  illness  as  a  result  of  the  continued  wast- 
ing and  the  gradual  weakening  of  the  heart.  In  infants 
a  transition  to  general  sepsis  is  not  uncommon.  At 
times  even  the  most  serious  cases  take  a  turn  for  the 
better  and  after  slow  convalescence  make  a  complete 
recovery.  In  fact,  recovery  is  always  gradual  and  the 
convalescence  is  interrupted  by  repeated  relapses  as 
serious  as  the  first  attack.  Even  in  the  most  favorable 
cases  the  pus  is  found  in  the  urine  for  weeks  or  months 
after  all  other  symptoms  have  disappeared,  so  that 
there  is  a  question  whether  some  of  the  patients  ever 
recover  completely.  And  those  that  do  recover  have 
a  certain  tendency  to  relapse  that  may  persist  even 
after  childhood.  Relapses  are  most  frequent  during 
the  first  few  months  of  convalescence. 

Secondary  pyelocystitis  may  persist  longer  than 
the  primary  disease  or  in  milder  cases  may  disappear 
when  the  primary  symptoms  disappear.  Cystitis  and 
pyelocystitis  of  older  children  is  more  liable  to  become 
chronic,  persisting  for  years.  It  is  fatal  in  exceptional 
cases  only. 

Diagnosis. — The  microscopic  examination  of  the 
urine  is  absolutely  necessary  in  making  a  diagnosis. 
The  fresh  urine  shows  a  diffuse  cloudiness  which,  par- 
ticularly, when  shaken,  resembles  the  curling  of  a  pillar 
of  smoke.  Hemorrhagic  discoloration  is  uncommon. 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM          443 

While  the  fresh  urine  has  no  characteristic  odor,  it  seems  to  decompose 
more  rapidly  at  the  temperature  of  the  bed  and  easily  becomes  so  unpleas- 
ant as  to  be  noticeable  to  the  attendant.  If  infection  is  due  to  the  colon 
bacillus,  the  reaction  of  the  urine  is,  as  a  rule,  acid,  while  an  alkalin  reaction 
is  exceptional.  Upon  settling  or  centrifuging,  a  surprisingly  large  amount 
of  whitish  slimy  sediment  is  often  seen.  Microscopically  this  is  seen  to 
consist  almost  entirely  of  pus  corpuscles  which  often  form  in  balls  or 
clusters.  In  the  acute  stage  a  variable  number  of  erythrocytes  is  found. 
A  tenacious  mucus-like  substance  may  be  recognized  in  cloudy  or  thread- 
like masses.  A  few  epithelial  cells,  usually  round  and  with  distinct  nuclei, 
are  found  among  the  leucocytes.  Casts  are  generally  absent,  even  when 
the  kidney  is  affected.  The  amount  of  protein  corresponds  in  a  general  way 
with  the  quantity  of  pus.  In  the  fresh  urine,  short  rods  actively  motile 
with  rounded  ends  are  seen  in  the  majority  of  specimens.  These  grow 
rapidly  upon  culture  media  and  are  Gram  negative.  The  complete  absence 
of  micro-organisms  in  the  stained  smear  suggests  tuberculosis.  The  differen- 
tial diagnosis  must  be  established  by  special  stains  and  guinea  pig  injections. 

These  urinary  findings  alone  suffice  for  diagnosis  if  the  rupture  of  pus 
into  the  urinary  tract  from  neighboring  inflammatory  foci,  e.g.,  peri  ty- 
phlitis, can  be  excluded.  It  is  usually  impossible  to  make  a  diagnosis  without 
examining  the  urine.  The  grayish-yellow  pallor  is  very  characteristic.  The 
routine  examination  for  protein  is  insufficient  for  the  amount  of  protein 
excreted  is  usually  very  small.  Every  child  that  is  ill  with  febrile  disease 
the  microscopic  examination  of  the  uncentrifuged  urine  is  imperative.  The 
urine  of  infants  suffering  from  acute  digestive  disturbances  should  be  care- 
fully watched  for  signs  of  pyelocystitis,  even  though  there  is  no  fever.  This 
is  the  only  wajr  in  which  serious  errors  in  diagnosis  may  be  avoided.  In 
older  children  the  differential  diagnosis  may  be  confused  with  typhoid  fever 
or  perityphlitis  while  in  infancy  the  clinical  picture,  which  in  the  stage  of 
irritability  may  be  complicated  by  general  hypertonia,  especially  of  the 
muscles  of  the  neck,  may  be  mistaken  for  that  of  epidemic  meningitis. 
Unless  there  are  distinct  local  sj'mptoms,  a  clinical  diagnosis  is  impossible 
in  infancy.  The  form  as  well  as  the  presence  or  absence  of  certain  epithelial 
cells,  are  extremely  unreliable  aids  in  diagnosis.  An  increase  of  protein  in 
the  urine  is  suggestive  of  pyelitis  or  disease  of  the  kidney  itself.  When  tuber- 
culosis is  suspected  cystoscopy  may  be  of  use  in  older  girls. 

Treatment. — While  much  can  be  accomplished  with  suitable  therapy, 
in  severe  cases  a  good  prognosis  cannot  be  insured.  The  patient  should  be 
kept  in  bed  until  the  urine  becomes  clear.  In  infants  and  younger  children 
the  diet  must  be  regulated  according  to  the  requirements  of  the  parenteral 
infection.  During  the  period  of  acute  manifestations  in  both  infants  and 
older  children,  the  symptoms  of  exudative  diathesis  must  be  treated. 
Liberal  diet  of  coarse  foods,  fruit  and  cereals,  is  advisable  to  prevent  con- 
stipation. Highly  spiced  foods  may  be  irritating.  With  this,  a  liberal 
lavage  of  the  kidney  with  large  amounts  of  water,  has  long  been  used.  Too 
much  emphasis  cannot  be  laid  upon  the  importance  of  this  water  treatment. 
In  infants  the  water  may  be  given  by  stomach  tube.  In  older  children,  the 


444  TEXT-BOOK  OF  PEDIATRICS 

addition  of  fruit  juices  and  other  flavoring  may  help  to  get  in  the  required 
amounts.  In  some  cases,  more  strenuous  measures  such  as  drop  method 
per  rectum,  intraperitoneal  or  subcutaneous  injection  may  have  to  be 
instituted.  At  least  \Y^  quarts  must  be  given  to  smaller  infants  in  the 
twenty-four  hour  period  and  as  much  more  as  possible  to  older  children. 

If  temperature  runs  high,  tepid  baths  35°  C.  (95°  F.)  are  refreshing 
and  stimulating.  If  the  body  temperature  falls,  the  temperature  of  the 
bath  may  be  increased  to  40°  C.  (104°  F.).  Internal  medication  with 
hexamethylenamine  (urotropin),  or  phenyl  salicylate  (salol)  is  often  of 
undeniable  value.  At  present,  hexamethylenamine  is  the  more  commonly 
used.  Five  to  eight  doses  a  day  of  the  aqueous  solution,  representing  a 
total  dosage  of  0.25-0.5  gm.  (3-7^  grs.),  for  infants,  or  1.0-1.5  gms.  (15- 
22  grs.),  for  older  children,  may  be  given.  The  more  obstinate  cases  are 
sometimes  favorably  influenced  by  phenyl  salicylate  given  in  the  same 
doses.  Finally,  hippol  [1.0-1.5  gms.  (15-22  grs.)  a  day],  or  naphthalin, 
[0.5  gm.  (7}/2  grs.),  three  times  a  day],  may  be  tried.  The  author  has 
found  the  alkalinization  of  the  urine  by  means  of  liberal  doses  of  potassium 
citrate,  as  recommended  by  Klotz,  very  effective.  No  other  internal  treat- 
ment is  used.  It  may  be  necessary  to  give  three  to  six  grams  per  day  in 
divided  doses  to  infants  and  three  to  ten  grams  to  older  children,  the 
amounts  to  be  controlled  by  testing  the  urine  with  litmus.  This,  together 
with  the  increase  of  the  volume  of  the  urine  as  a  result  of  the  ingestion  of 
large  amounts  of  water,  is  the  treatment  most  commonly  used  at  present. 
Local  treatment  by  lavage  is  applicable  only  in  cases  of  pure  cystitis  and 
should  be  considered  only  when  the  disease  continues  for  a  long  time  and 
other  remedies  have  proved  useless.  In  the  administration  of  lavage  all 
pressure  must  be  avoided.  A  3  per  cent,  solution  of  boric  acid  is  used  first; 
this  is  followed  by  a  solution  of  silver  nitrate  (1-4000)  which  should  be  with- 
drawn after  its  use  has  been  continued  for  five  or  ten  minutes,  when  the 
bladder  is  to  be  thoroughly  rinsed  with  a  physiologic  salt  solution.  Local 
heat  in  the  form  of  cataplasms  may  be  employed  to  relieve  pain  and  tenes- 
mus.  Vaccine  therapy  is  of  no  value  in  cases  of  colon  infection,  but  occa- 
sionally effects  a  cure  when  the  disease  is  caused  by  other  organisms.  The 
treatment  of  tuberculosis  of  the  genito-urinary  tract  consists  of  removal  of 
the  affected  kidney  after  determining  the  function  and  normality  of  the 
other  kidney.  This  applies  no  matter  what  portion  of  the  tract  is  affected. 

As  a  prophylactic  measure  it  is  essential  that  extreme  care  be  exercised 
in  preventing  fecal  matter  from  being  forced  into  the  urethra.  The  patient 
must  be  protected  from  cold  and  exposure. 

Hematuria  and  Hemoglobinuria. — Hematuria,  the  evacuation  of  urine 
containing  blood,  is  a  symptom  of  various  diseases  of  the  urinary  tract. 
The  urine  is  abnormally  colored,  the  shade  varying  from  yellowish-red 
to  a  dark  red  or  a  brownish-red.  It  is  cloudy  and  often  dichroic.  In  the 
sediment  large  numbers  of  fresh  or  laked  red  blood-corpuscles  are  to  be 
seen.  Mild  degrees  of  hematuria  can  be  demonstrated  only  by  means 
of  the  microscope. 

Apart  from  hemorrhagic  nephritis,  hematuria  often  occurs  after  trau- 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         445 

mata  in  the  region  of  the  kidney.  It  may  accompany  renal  or  cystic  calcu- 
lus, or  neoplasms  of  the  kidney.  It  is  seen  in  tuberculosis  of  the  kidney  or  of 
the  urinary  passages;  in  embolic  or  thrombotic  conditions  and  in  hemorrhagic 
diathesis.  Mild  hematuria  may  be  an  early  symptom  of  infantile  scurvy. 

When  it  is  impossible  to  trea,t  the  underlying  conditon  and  this  is 
usually  relieved  by  surgical  measures,  the  hemorrhage  itself  may  be  com- 
bated to  advantage  by  rest  and  by  the  application  of  cold  or,  at  times, 
by  gelatin,  either  subcutaneously  or  by  mouth,  or  transfusion. 

Hemoglobirmria  is  the  term  used  when  discoloration  of  the  urine  is  due 
largely  to  free  blood  pigment  and  some  debris  of  red  blood-cells.  The  former 
is  usually  found  as  methemoglobin  and  gives  the  urine  a  more  or  less  reddish 
color.  Hemoglobinuria  may  be  caused  by  such  ectogenous  poisons  as  the 
chlorine  salts,  phenol,  naphthol,  hydrogen  sulphide,  anilin,  mushroom 
toxines,  etc.  It  is  occasionally  met  with  as  a  sequel  of  such  infectious 
diseases  as  scarlet  fever  and  malaria. 

Paroxysmal  hemoglobimiria  is  a  disease  in  which  hemoglobin  containing 
urine  is  voided  at  varying  intervals  of  time.  The  condition  is  rare,  but  it 
does  occur  in  childhood.  General  symptoms  usually  usher  in  the  attack. 
A  chill,  frequently  followed  by  a  rise  of  temperature ;  the  excessive  desire  to 
urinate,  pallor,  mild  cyanosis  or  icterus,  and  slight  proteinuria  are  observed. 
It  usually  lasts  but  a  few  hours,  when  the  patient  again  becomes  normal. 
Apparently,  the  paroxysm  is  most  frequently  brought  on  by  exposure  to 
cold.  The  real  nature  of  the  disease  is  unknown.  Congenital  syphilis  is 
present  in  the  large  majority  of  cases.  The  treatment  consists  in  the  prophy- 
lactic avoidance  of  the  injury  suspected  of  exciting  the  attack.  In  specific 
cases  it  should  be  directed  against  the  general  disease. 

DIABETES  INSIPIDUS 

Diabetes  insipidus,  while  rare,  is  relatively  frequent  in  later  childhood. 
It  is  probably  congenital,  developing  gradually.  The  attention  of  the  par- 
ents is  usually  called  to  the  condition  by  the  excessive  thirst  rather  than  by 
the  large  amounts  of  urine.  The  child  may  become  so  thirsty  that,  if 
sufficient  water  is  not  supplied,  he  will  drink  the  water  of  the  bath  or  toilet. 
There  is  no  doubt,  however,  that  polydipsia  is  not  the  primary  symptom. 
The  thirst  is  the  result  of  the  enormous  excretion  of  urine.  The  increased 
quantity  of  urine  in  cases  in  which  the  kidney  shows  no  pathology  is  sup- 
posed, according  to  E.  Meyer,  to  be  due  to  lack  of  the  power  of  concentra- 
tion with  normal  power  of  diluting  the  urine.  Large  amounts  of  fluid  are 
required,  therefore,  to  remove  the  debris  of  metabolism.  The  twenty-four 
hour  quantity  is  increased  to  several  litres  (quarts).  In  severe  cases,  this 
may  even  equal  the  body-weight.  The  urine  is  very  light  colored  and  the 
specific  gravity  may  be  as  low  as  1.002  to  1.004.  The  total  solids  is  usually 
about  normal  so  that  there  is  no  retention.  The  frequency  of  micturition 
and  the  quantity  of  urine  increases  and  enuresis  is  a  frequent  complication. 
The  blood-pressure  is  normal. 

The  general  health  of  the  patient  is  affected  because  of  the  unquenchable 
thirst,  which  interferes  with  sleep  arid  makes  the  child  morose.  Generally 


446  TEXT-BOOK  OF  PEDIATRICS 

the  need  of  fluid  causes  anorexia.  The  child  loses  weight  at  first,  and  the 
general  development  is  retarded.  The  secretion  of  saliva  and  perspiration 
may  be  greatly  reduced  so  that  the  mouth  and  skin  are  abnormally  dry. 
Because  of  the  large  amounts  of  cold  water  ingested,  the  body  temperature 
may  be  subnormal.  Trophic  disturbances  of  the  hair  and  nails  are  seen. 

The  duration  is  usually  difficult  to  prognosticate.  It  usually  persists 
for  years  and,  in  occasional  cases,  to  old  age.  Spontaneous  recovery  may 
take  place  if  intercurrent  disease  does  not  cause  death. 

The  diagnosis  is  made  by  means  of  functional  tests  with  sodium  chloride 
or  protein.  A  diet  low  in  these  food  elements  reduces  the  excretion.  When 
they  are  again  added,  the  amount  of  urine  increases  and  both  substances,  or 
one  or  the  other,  are  fully  excreted  without  increasing  the  specific  gravity 
of  the  urine  or  increasing  the  per  cent,  of  their  products.  The  concentra- 
tion of  sodium  chloride  and  nitrogen  in  the  blood  may  increase  and  this 
may  be  dangerous. 

In  the  differential  diagnosis  various  conditions  must  be  ruled  out. 

In  diabetes  melitus,  the  specific  gravity  of  the  urine  is  high,  it  contains 
sugar  and  acetone  bodies — contracted  kidney  is  characterized  by  increased 
blood-pressure  and  retention.  Pyelitis  is  differentiated  by  the  presence  of 
pus.  Primary  nervous  polydipsia  of  childhood  may  be  distinguished  by  the 
facts  that  the  quantities  of  urine  are  not  as  great  and  the  power  of  concen- 
tration is  not  lost. 

The  cause  of  diabetes  insipidus  is  unknown.  Heredity  and  nervousness 
may  occasionally  bo  factors.  Commotio  cerebri  may  bring  on  the  disease. 
Tumor  of  the  hypophysis  or  pressure  on  this  organ  may  be  a  cause.  Occa- 
sionally congenital  adipose  dystrophy  may  be  associated.  All  of  these  latter 
points  as  well  as  the  transient  benefit  obtained  by  the  injection  of  extract 
of  the  hypophysis,  according  to  the  method  of  Velde  and  Johns,  seem  to 
point  to  the  possibility  of  a  functional  disturbance  of  the  pars  intermedia  of 
this  gland.  Some  authors  consider  injury  or  abnormality  in  the  region  of 
the  infundibulum.  It  may  be  possible  that  the  function  of  the  pancreas 
is  involved. 

Therapy. — Pituitary  extract  acts  specifically  in  controlling  the  condi- 
tion. A  salt-free  diet,  not  too  rich  in  protein,  which  combines  large  quanti- 
ties of  fluid  with  its  nutrient  elements  in  the  form  of  fruits,  vegetables, 
milk,  thick  soup,  etc.,  should  be  chosen.  Attempts  should  be  made  to 
reduce  the  quantity  of  fluid  taken  very  gradually.  This  endeavor  demands 
patience  and  judgment,  since  especially  in  true  diabetes  insipidus  the  too 
rapid  reduction  of  fluid  may  induce  serious  results.  Measures  directed 
to  the  stimulation  of  the  peripheral  circulation  and  designed  to  divert 
the  patient 's  attention  from  the  conspicuous  feature  of  his  general  condi- 
tion should  be  instituted.  Fresh  air,  recreative  exercise,  warm  or  tepid 
baths  and  sun-baths  may  be  suggested. 

ENURESIS 

The  normal  child  acquires  voluntary  control  over  the  urinary  sphincter, 
during  the  daytime,  by  the  end  of  the  second  year.  Occasionally  this  con- 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         447 

trol  may  fail,  in  the  nighttime,  until  late  in  the  third  year.  The  period  at 
which  a  child  acquires  essential  habits  of  cleanliness  depends  largely  upon 
the  care  that  it  receives  and  the  pedagogic  skill  of  its  attendants,  as  well  as 
upon  its  own  physical  and  intellectual  development. 

When  the  influences  of  training  fall  upon  inherently  poor  soil  the  results 
will  naturally  be  delayed  and  may  never  be  achieved.  Debilitated  and 
imbecile  children  are  slow  in  learning  to  make  their  wants  known,  while 
the  idiotic  never  learn.  Even  serious  interferences  with  physical  develop- 
ment occurring  at  an  early  period,  will  delay  the  acquirement  of  habits 
of  cleanliness. 

There  are  children,  however,  in  whom  none  of  these  unfortunate  condi- 
tions are  found,  in  whom,  notwithstanding  the  most  tedious  training,  it  is 
impossible  to  establish  the  volitional  control  of  micturition  or  in  whom  its 
attainment  is  delayed  for  a  number  of  years.  There  are  still  others  in 
whom  control,  acquired  with  great  difficulty,  is  again  lost  for  an  indefinite 
period  as  the  result  of  some  intercurrent  disease. 

The  sudden  and  entirely  involuntary  voiding  of  large  quantities  of 
urine,  without  evidence  of  desire  to  urinate  or  even  of  excessive  distension  of 
the  bladder,  is  termed  enuresis.  As  a  rule,  it  occurs  only  at  night  and  is 
known  as  nocturnal  enuresis.  It  happens  very  rarely  during  the  day  and 
only  under  the  momentary  influence  of  strong  mental  diversion,  as  during 
active  play,  excitement,  fear  or  physical  exertion  (diurnal  enuresis).  Dis- 
turbances of  micturition  which  are  due  to  structural  lesions  of  the  cord,  or 
are  incident  to  loss  of  consciousness  resulting  from  disease,  are  not  included 
in  this  conception  of  enuresis.  Neither  does  the  term  apply  to  those  con- 
ditions in  which  the  causative  factor  is  a  pathologic  increase  in  the  output  of 
urine,  with  consequently  frequent  desire  to  urinate  as  in  diabetes,  cystitis, 
lithiasis,  etc. 

After  the  exclusion  of  all  above  pathology,  the  remaining  condition  does 
not  in  itself  constitute  a  distinct  disease  entity.  A  number  of  children  are 
found  in  whom  involuntary  micturition  has  not  occurred  since  early  child- 
hood but  develops  after  the  fifth  year.  The  accident  does  not  happen 
regularly  night  after  night,  but  occurs  occasionally,  or  in  a  short  sequence 
with  long  intervals  of  respite.  In  such  cases  the  enuresis  may  be  but  a 
minor  manifestation  accompanying  unobserved  nocturnal  epileptic  dis- 
charges. This  relationship  should  be  suspected  when  such  intermissions 
occur  and  when  attacks  of  dizziness,  peevishness,  exhaustion  upon  awaken- 
ing, and  a  bitten  tongue  are  observed.  (Pfister.) 

Some  cases  of  bed-wetting  may  be  classed  as  manifestations  of  juvenile 
hysteria.  In  these  individuals  the  symptom  first  appears  in  relation  to 
external  events  and  disappears  rapidly  and  for  all  time  under  psychic  treat- 
ment. This  type  of  case  is  probably  well  illustrated  in  the  psychic  infection 
which  has  been  known  to  spread  the  disorder  among  a  large  number  of 
boys  in  a  school  dormitory. 

The  typical  and  common  form  of  enuresis,  however,  affects  children  of 
all  ages  up  to  and  even  beyond  puberty.  Most  of  these  patients  have  either 
never  fully  acquired  habits  of  cleanliness,  or  have  broke  a  their  acquired 


448  TEXT-BOOK  OF  PEDIATRICS 

habits  in  the  course  of  intercurrent  disease;  a  few  among  them  have  lost 
control  for  no  accountable  reason.  In  severe  cases  nocturnal  micturition 
occurs  every  night,  while  in  milder  ones  there  may  be  intervals  of  days  and 
weeks  during  which  they  do  not  wet  the  bed.  The  accident  generally 
occurs  in  the  early  hours  of  the  night  and  usually  before  midnight,  but  it 
may  be  repeated  several  times  during  the  hours  of  deep.  The  child  is  not 
awakened  at.  all  or  maybe  aroused  by  the  cold  wet  bedding.  The  bladder 
is  not  necessarily  distended.  Micturition  may  occur  at  the  hour  when  the 
child  has  been  accustomed  to  empty  the  bladder,  if  it  has  not  been  given  the 
opportunity  to  do  so. 

A  large  majority  of  children  who  suffer  with  enuresis  belong  to  this  class. 
The  signs  common  in  these  cases,  which  unite  them  in  a  single  group,  do  not 
always  stand  out  clearly  but  may  be  looked  for  and  developed  by  inquiry. 
Too  much  stress  must  not  be  laid  upon  any  accidentally  etiologic  factor, 
but  an  attempt  must  rather  be  made  to  determine  the  basis  for  the  fact 
that  stimuli,  not  ordinarily  causative  of  such  a  result  produce  the  symptom. 
In  enuresis,  it  is  impossible  to  discover  a  local  neurosis  of  the  bladder. 
There  are  cases  in  which  the  local  symptom  is  overshadowed  by  the  general 
impression  of  an  abnormally  predisposed  personality.  In  some  instances 
distinct  physical  and  psychical  signs  of  degeneration  are  to  be  noted,  while 
in  others  they  are  merely  suggested  or  masked.  Among  the  physical  signs, 
anomalies  in  the  formation  of  the  head,  face  and  teeth  are  observed,  while 
the  nervous  and  physical  indications  include  exaggerated  reflexes,  vaso- 
motor  irritability,  sudden  localized  sweats  and  such  varied  disturbances  of 
innervation  as  errors  of  speech,  sleep-talking,  somnambulism,  pavor  noc- 
turnus,  capricious  moods,  and  a  secretive  disposition.  Finally,  as  a  key  to 
the  entire  situation,  a  bad  family  history  may  be  found.  In  this  picture  the 
enuresis  loses  the  importance  of  an  independent  functional  disease*.  It  takes 
its  place  as  one  among  other  symptoms,  prominent  merely  in  its  frequency 
and  in  the  attention  it  attracts,  but  serving  as  a  sign  of  hereditary  stigmata 
and  degenerative  inferiority. 

It  is  in  the  soil  of  such  a  neurosis  that  the  disturbance  develops  and  in 
which  it  is  cultivated  by  other  and  exciting  influences.  Oxyuris,  mastur- 
bation, phimosis,  vulvitis,  balanitis,  eczema  of  the  genitalia,  adenoid  vege^ 
tations,  etc.,  may  be  among  such  influences.  An  abnormal  soundness  of 
slumber  cannot  be  regarded,  in  itself,  as  an  etiologic  factor. 

Prognosis. — A  prognosis  is  difficult  in  individual  cases.  The  disturbance 
may  disappear  at  any  time  without  therapeutic  interference.  In  fact,  this 
has  often  occurred  suddenly  without  known  cause,  although  it  is  generally 
a  more  gradual  improvement  and  related  to  some  definite  event  or  to  change 
of  environment.  Almost  any  form  of  treatment  may  give  surprising  tem- 
porary results.  In  severe  cases  it  is  not  well  to  put  too  great  faith  in  the 
permanency  of  results.  Most  cases  recover  spontaneously  during  childhood. 
Occasionally  an  exacerbation  occurs  at  puberty. 

Therapy. — There  is  no  specific  therapy,  and,  for  this  reason,  the  list  of 
remedies  that  have  been  advocated  are  endless.  Since  every  successful 
remedy  has  only  a  psychic  influence,  there  should  be  no  trouble  in  effecting 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         449 

frequent  changes,  since  the  psychic  impression  soon  loses  •  its  efficacy. 
Whether  we  prohibit  liquids  at  supper-time,  or  raise  the  foot  of  the  bed,  or 
prescribe  the  old  favorite  fluid  extract  of  rhus  glabra,  or  apply  adhesive 
plaster  on  the  bladder  region,  the  mental  suggestion  always  plays  the  most 
important  part.  The  application  of  the  faradic  current,  of  sufficient 
strength  to  cause  slight  pain,  or  the  use  of  hypnotic  suggestion  have  more 
lasting  effects  and  are  more  impressive.  Occasionally  regular  habits  are 
formed  by  rousing  the  child  at  stated  intervals.  Medicinally,  strychnin  and, 
more  especially,  atropin  [0.02  gm.  (%  gr.)  in  10  c.c.  (2%  drams)  of  water; 
one  drop  for  each  year  of  age],  have  come  into  favor. 

With  all  the  symptomatic  therapy,  the  improvement  of  the  general  con- 
dition of  the  weak  and  delicate  child  by  suitable  nourishment,  massage, 
stimulating  hydrotherapy  and  fresh  air,  must  not  be  forgotten.  By  far  the 
best  results  are  obtained  by  skilful  psycho-pedagogic  treatment.  This 
method  strives  to  increase  the  self-reliance  of  the  patient  by  sensible  encour- 
agement and  psychic  aid,  while  the  attention  and  the  will-power  are  being 
trained  by  various  pedagogic  measures,  Success  may  be  greatly  assured  by 
removing  the  child  to  new  and  strange  surroundings,  as  in  placing  it  under 
institutional  care. 

VULVO-VAGINITIS 

In  girls  who  have  not  reached  the  period  of  puberty  various  etiologic 
factors  may  produce  inflammation  of  the  genital  organs  with  pathologically 
increased  secretion. 

The  desquamative  catarrh  of  the  new-born,  in  which  a  gelatinous  or 
caseous  secretion  containing  numerous  epithelial  cells  and  very  few  leuco- 
cytes, is  but  one  manifestation  of  the  general  desquamation  of  the  body  sur- 
face which  occurs  after  birth. 

The  mucopurulent  secretion  occurring  with  a  low  order  of  inflam- 
mation in  older  infants  is  usually  an  indication  of  the  exudative  diathesis. 
Contagious  impetigo,  herpes,  and  eruptions  following  vaccination  may  ap- 
pear on  the  mucous  membrane  of  the  genitalia  and  may  cause  an  atypical 
inflammatory  secretion  after  the  more  or  less  characteristic  primary  erup- 
tion has  subsided.  The  genital  mucous  membranes  may  also  participate 
in  the  general  eruption  of  scarlet  fever,  measles,  or  small-pox.  Inflamma- 
tion may  result  from  the  presence  of  foreign  bodies  or  of  oxyuris,  or 
from  masturbation. 

Purulent  gonorrhceal  vulvo-vaginitis  is  of  much  greater  consequence. 
Its  micro-organism,  the  gonococcus  of  Neisser,  is  identical  with  that  of 
gonorrhoea  in  the  adult.  Marked  differences  in  the  pathogenesis,  the  local- 
ization and  the  course  of  the  disease  made  it  difficult,  at  first,  to  recognize 
its  identity;  but  to-day  there  can  be  no  doubt  that  these  differences  are  not 
dependent  upon  the  organism  but  rather  upon  its  different  habitat  incident 
to  the  age  of  its  host. 

While  gonorrhceal  infection  hardly  ever  occurs  in  adult  females  except 
through  direct  contact  in  sexual,  intercourse,  practically,  it  is  never  trans- 
ferred in  this  way  to  the  young.  The  majority  of  girls  who  have  gonorrhceal 
29 


450  TEXT-BOOK  OF  PEDIATRICS 

disease  acquire  it  by  indirect  contact.  The  infection  is  carried  by  polluted 
hands,  by  the  thermometer,  by  wash-cloths  or  by  clothing.  Careful  inquiry 
will  usually  point  to  some  adult  of  the  family  as  the  author  of  the  infection. 
Generally  the  mother,  suffering  supposedly  \\  ith  leucorrhcea,  is  the  source, 
or  the  infection  is  carried  from  the  eyes  of  the  child  where  it  had  been  first 
implanted  and  whence  it  has  been  transferred  to  the  genitals.  The  mucous 
membranes  of  the  external  genitals  at  certain  ages  are  so  prone,  in  fact,  to 
this  infection  that  the  disease  will  pass  from  child  to  child  in  epidemic-like 
form  in  hospitals,  resorts,  public  baths,  etc.,  even  though  the  general  hy- 
giene is  good. 

Occurrence. — -A  predisposition  in  female  children,  limited  alike  by  age 
and  by  local  conditions,  is  shown  not  only  by  the  fact  that  small  boys  are 
almost  invariably  spared  from  uro-genital  blennorrhcea  but  also  by  the 
evidence  that  in  girls  there  is  a  period,  between  childhood  and  maturity,  in 
which  the  disease  almost  wholly  disappears.  The  condition  is  observed  in 
the  new-born  of  gonorrhoeal  mothers,  the  infection  supposedly  taking  place 
during  delivery;  but  vaginal  disease  in  the  child  at  this  period  is  much  less 
common  than  gonorrhoeal  conjunctivitis.  In  the  former  locality  it  is  most 
frequent  between  the  second  and  the  seventh  to  the  tenth  years. 

Symptoms. — The  inflammatory  process  is  localized  in  the  mucous  mem- 
branes of  the  external  genitals  and  the  vestibule,  together  with  the  orifices 
of  Bartholin  's  glands;  the  navicular  fossa  and  the  labium  minora  are  its  most 
common  seats.  In  contrast  with  its  exhibitions  at  a  later  age  the  vaginal 
mucous  membrane  is  more  seriously  affected.  The  transit  of  the  disease 
process  to  the  endometrium  or  even  to  the  tubes  is  exceptional. 

The  disease  is  active  after  an  incubation  period  of  about  three  or  four 
days  with  but  slight  manifestations.  Subjective  symptoms  may  be  entirely 
wanting.  Pain  on  walking  or  sitting  and  a  burning  sensation  upon  urinating 
occur  only  when  abrasions  or  manifestations  of  eczematous  irritation  of  the 
neighboring  skin  have  been  caused  by  a  lack  of  care  and  cleanliness.  The 
desire  to  urinate  is  at  times  increased.  The  general  well-being  is  often  undis- 
turbed and  the  patient  continues  to  look  fresh  and  rosy.  The  at  tent  io  a  is 
often  first  attracted  to  the  infection  by  the  yellowish  spots  of  dried  secretion 
appearing  upon  the  linen. 

In  the  acute  stage  inspection  of  the  genitals  may  be  painful.  When  the 
labium  majoraare  spread  apart  their  contact  surf  aces  are  found  symmetrically 
reddened  and  covered  with  a  stringy  secretion  which  forms  greenish-yellow 
crusts  upon  the  external  margins.  The  region  of  the  vestibular  glands  and 
the  urethra]  orifice  are  bright  red  and  covered  with  a  thick  yellowish  pus 
which  is  retained  by  the  swollen  and  edematous  hymen.  Large  quantities 
of  pus  can  be  expressed  from  the  vagina  by  the  finger  introduced  into  the 
rectum,  showing  the  marked  involvement  of  the  vaginal  mucous  membrane. 
The  inguinal  glands  may  be  moderately  swollen.  The  involvement  of  the 
urethra  and  bladder  is  rare — the  infection  of  the  endometrium  to  the  tubes 
slightly  more  frequent;  the  anal  mucosa  on  the  other  hand  is  frequently 
affected.  Gonococci  have  been  found  on  the  nasal  mucosa. 

In  the  stained  smear  of  the  secretion  are  found  numerous  pus  cells  and 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         451 

typically  located  Gram-negative  diplococci  of  characteristic  form.  Their 
demonstration  is  essential  to  the  differentiation  of  the  disease  from  other 
causes  productive  of  mucopurulent,  secretions.  Various  forms  of  diplococci 
are  not  uncommon  in  the  genital  secretions  and  the  diagnosis  depends 
therefore  upon  their  form  and  position. 

Course. — The  course  of  the  disease  is  distinctly  chronic.  Even  though 
the  acute  symptoms  of  inflammation  are  soon  overcome  the  secretion  rarely 
disappears  completely  within  four  to  eight  weeks;  or,  greatly  reduced  in 
quantity,  may  continue  for  months.  Cases,  in  which  distinct  remissions 
occur,  may  persist  for  years.  The  most  careful  and  active  treatment  may 
not  succeed  in  completely  arresting  the  secretion,  but  only  results  in  partial 
recovery.  Thus,  even  though  there  is  no  actual  danger  to  life  involved,  the 
prognosis  is  unfavorable  because  of  the  long  duration  of  the  disease.  Com- 
plications by  extension  to  the  bladder,  the  internal  genitals  and  the  peri- 
toneum are  rare,  nor  is  the  infection  very  often  carried  to  the  eye  even  though 
the  ease  is  not  given  as  scrupulous  care  as  it  should.  The  gonorrhceal 
infection  of  single  joints  is  a  more  frequent  matter. 

Prophylaxis. — Preventive  measure  should  guard  young  girls  from  care- 
less contact  with  goncrrhreal  adults  or  with  articles  used  by  them.  They 
should  sleep  alone.  The  genital  regions  should  be  kept  clean  by  frequent 
washing.  In  institutions  the  infected  patient  must  be  isolated.  Individual 
toilet  articles  are  indispensable. 

Treatment. — In  the  treatment  of  the  acute  stage  rest  in  bed  is  essential. 
To  diminish  the  danger  of  the  spread  of  the  disease  it  is  well  to  use  a  T- 
bandage  and  to  have  the  patient  wear  closed  drawers  when  out  of  bed.  The 
unpleasant  results  caused  by  the  free  flow  of  pus  may  be  avoided  by  frequent 
irrigation  of  the  well  separated  parts  with  weak  saturations  of  potassium 
permanganate  either  expressed  from  a  piece  of  cotton  or  applied  by  use  of 
an  irrigator.  With  the  patient  in  the  cystotomy  position,  the  vulva  directed 
upwards,  a  1  to  3  per  cent,  solution  of  protargol  or  20  per  cent,  argyrol  is 
instilled  into  the  parts,  from  two  to  four  times  a  day,  from  a  cotton  tampon, 
which  is  then  applied  externally  and  left  in  place  for  ten  minutes.  The 
remaining  solution  is  not  removed.  Sitz  baths,  containing  an  astringent, 
such  as  tannin,  aid  in  preserving  local  cleanliness.  Irrigations  of  the  vagina, 
to  which  there  may  be  physiologic  and  pedagogic  objections,  are  not  essen- 
tial. If  they  should  become  necessary  they  may  be  given  with  a  soft  rubber 
catheter  and  an  irrigator,  using  a  weak  solution  of  potassium  permanganate 
at  body  temperature.  The  use  of  iodoform  vaginal  suppositories  and  the 
dusting  of  the  interior  of  the  vagina  with  diy  sterilized  bolus  alba  have  been 
frequently  advised.  It  is  customary  to  give  various  balsams,  such  as 
santal  oil  (5-15  drops  three  times  daily)  internally.  Gonococcus  vaccine  is 
useful  in  the  gonorrhceal  rheumatism  only.  The  overheating  of  the  body 
by  the  use  of  hot  baths  is  dangerous,  intravenous  injection  of  silver  salts 
is  useless. 

The  condition  may  be  said  to  be  cured  when  after  repeated  diligent 
search,  following  irritation  of  the  vaginal  mucosa  with  strong  silver  solution, 


452  TEXT-BOOK  OF  PEDIATRICS 

no  gonococci  can  be  demonstrated  in  stained  smears  and  this  must  be 
repeated  for  several  weeks. 

PHIMOSIS,  PARAPHIMOSIS,  AND  BALANITIS 

It  is  generally  impossible  to  retract  the  prepuce  sufficiently  to  expose 
the  glans  penis  to  view.  Upon  close  examination  it  is  often  found  that  the 
inner  surface  of  the  prepuce  is  closely  adherent  to  the  glans  even  as  far  for- 
ward as  the  funnel-like  meatus.  In  some  individuals  the  prepuce  extends 
beyond  the  glans  so  that  it  is  sometimes  difficult  to  inspect  the  urinary 
meatus.  Either  condition  may  be  considered  normal  and  should  not  cause 
the  least  anxiety.  In  fact  the  synechia  between  the  glans  and  the  prepuce 
are  due  to  congenital  and  entirely  physiologic  epithelial  adhesion  which 
disappears  spontaneously  from  before  backwards  during  the  early  years. 

Even  an  apparently  small  preputial  opening  does  not,  as  a  rule,  hinder 
the  evacuation  of  urine  because  it  distends  under  the  pressure  of  the 
stream.  The  condition  is  pathologic  only  when  the  urine  dribbles  from  the 
opening,  while  the  child  strains  and  cries,  and  the  free  end  of  the  preputial 
sac  is  filled  and  distended  with  urine.  This  is  due  to  a  stenosis  of  the  pre- 
putial canal,  which  is  termed  phimosis. 

In  these  rare  cases  we  occasionally  find  objective  symptoms  of  retention 
of  urine.  Less  severe  degrees  of  constriction  may  cause  disturbance  of 
function  if  inflammatory  changes  develop  in  the  tissues  concerned.  These 
may  occur  when  smegma  and  small  portions  of  urine  decompose  in  the  sac 
and  produce  irritations,  redness  and  edema  of  the  free  surfaces.  Then  the 
distal  part  of  the  organ  may  become  swollen  to  an  extreme  degree.  A 
purulent  secretion  may  be  expressed  from  the  narrow  slit-like  preputial 
opening,  causing  extreme  pain.  This  condition  is  known  as  balanitis  or 
balanoposthitis. 

While  these  typical  symptoms  are  easily  recognizable  and  the  functional 
disturbances  caused  by  them  are  undeniable,  the  statements  and  the  inter- 
pretations of  the  mother  concerning  them  must  always  be  accepted  with 
utmost  caution.  At  practically  all  levels  of  society  the  genital  organs  of  the 
infant  receive  a  special  measure  of  anxious  and  careful  observation.  With 
the  exception  of  the  teeth,  no  other  organ  is  suspected  of  so  frequent  and 
varied  pathogenetic  influence,  nor  is  the  physician  more  frequently  con- 
sulted for  disorder  of  any  other  part.  The  every  day  report  that  the  child 
cries  before  passing  urine  has  its  probable  explanation  in  the  fact  that  the 
infant  often  empties  the  well-filled  bladder  while  it  is  crying  and  straining 
from  some  other  cause. 

The  opinions  of  the  laity  will  surprise  us  the  less  when  we  consider 
how  many  physicians  are  prone  to  consider  slight  constriction  of  the  fore- 
skin an  etiologic  factor  in  severe  and  varying  disturbances,  especially  of  a 
nervous  order,  and  treat  their  patients  with  this  view. 

The  surgical  treatment  of  phimosis  is  indicated  in  a  small  number  of 
cases  and,  then  only,  when  these  cases  show  severe  symptoms  of  recurrent 
balanoposthitis  or  when  evidences  of  chronic  irritation  appear.  In  milder 
cases  the  prepuce  may  be  stretched  by  manipulation  or  with  blunt  instru- 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM         453 

ments.  The  adhesions  which  cause  the  retention  of  large  masses  of  smegma 
may  be  broken  with  a  probe. 

Inflammatory  conditions  should  be  treated  with  applications  of  a  cold 
boric  acid  solution  or  by  careful  irrigation  of  the  preputial  sac. 

Before  advocating  surgical  procedure  it  is  well  to  exclude  or  treat 
spasmophilia,  for  spasms  of  the  urinary  sphincter  and  even  eclamptic 
attacks  may  be  manifestions  of  this  condition.  In  the  differential  diag- 
nosis the  congenital  atresia  or  stricture  of  the  urethra  must  also  be  taken 
into  consideration. 

HYDROCELE  (SEROUS  PERIORCHITIS) 

Fluid  exudates,  between  the  parietal  and  visceral  layers  of  the  tunica 
vaginalis  of  the  testes,  are  extraordinarily  frequent  during  the  first  year  of 
life.  As  a  rule  the  serous  exudate  is  of  moderate  degree  and  involves  only 
one  side  of  the  scrotum.  Hemorrhagic  or  purulent  exudates  are  very  rare. 
Occasionally  the  exudate  extends  up  along  the  spermatic  cord  or  may  be 
entirely  localized  in  the  funicular  process.  The  swelling  may  be  present 
at  birth  or  it  may  develop  gradually  soon  after  birth.  It  does  not  cause  any 
special  symptoms,  nor  do  any  dangers  arise  from  it.  Hydrocele  is  relatively 
frequent  in  children  who  suffer  disturbances  of  nutrition.  It  may  disappear 
as  gradually  as  it  comes,  with  only  indifferent  treatment  or  with  none.  The 
skin  should  be  well  cared  for;  the  genital  region  must  be  kept  clean;  and 
any  existing  intertrigo  should  be  treated.  Operative  interference  is  not 
urgent.  If  the  tumor  becomes  very  large,  or  distends  the  scrotum  or  if  it 
persists  for  months  some  measure  of  surgical  aid  may  be  sought,  as  by  punc- 
ture or  injection  of  Lugol's  solution. 

'ANOMALIES  IN  POSITION  OF  THE  TESTES 

The  migration  of  the  testis  in  the  course  of  development  from  the  point 
of  formation  in  the  abdominal  cavity  to  its  final  position  in  the  scrotum  is 
occasionally  incomplete  at  birth  and  may  be  halted  at  any  point  in  its 
path.  If  the  interruption  in  its  descent  occurs  within  the  abdominal  cavity 
the  condition  is  known  as  cryptorchidism  or  monorchism.  The  arrest  in  its 
course  commonly  occurs  in  the  inguinal  canal  or  at  its  orifice.  The  scrotum 
is  empty  upon  one  or  both  sides,  while  the  misplaced  testis  may  often  be 
palpated  in  the  neighborhood  of  the  inguinal  canal.  This  delay  in  develop- 
ment is  not  uncommon  in  the  new-born,  but  the  malposition  may  correct 
itself  in  the  course  of  the  first  year  or  even  much  later. 

The  importance  of  the  malposition,  pathologically,  lies  in  the  fact  that 
the  retained  testicle  is  prone  to  diseases  of  various  sorts.  Fibroid  or  fatty 
changes  may  develop  in  it  or  it  may  become  the  focus  of  severe  inflam- 
matory processes.  In  later  life,  malignant  neoplasms  are  occasionally  grafted 
upon  it. 

Inflammation  of  the  testicle  situated  in  the  inguinal  canal  may  be 
mistaken  for  an  incarcerated  hernia.  It  is  also  true  that  incomplete  descent 
is  not  infrequently  associated  with  an  inguinal  hernia  and  may  be  a  factor 
in  its  causation. 


454  TEXT-BOOK  OF  PEDIATRICS 

Treatment. — If  it  can  be  palpated  an  attempt  may  be  made  to  bring  a 
retained  testis  to  its  normal  position  by  manipulation.  If  its  descent  does 
not  occur  spontaneously  nor  in  response  to  such  manipulation  by  the  tenth 
to  the  twelfth  year,  surgical  measures,  either  by  way  of  orchidopexy  or 
extirpation,  must  be  considered. 

MASTURBATION 

Latent  voluptuous  excitement  in  the  realm  of  the  genital  organs  may 
be  actualized  long  before  sexual  maturity.  In  fact,  its  vague  indefinite  indi- 
cations may  be  traced  to  the  earliest  infancy.  These  sensations,  periph- 
erally produced,  become  associated  with  potential  mental  processes  to 
constitute  the  phenomenon  of  conscious  sexual  sense  much  later.  The 
intensity  and  the  period  of  this  development  are  the  subject  of  great  indi- 
vidual differences. 

The  earliest  voluptuous  sensations  arising  in  the  genital  organs  are 
accidentally  discovered.  Probably  they  are  frequently  brought  to  the  child's 
attention  in  the  course  of  its  play  and  as  a  result  of  its  normal  inquisitive- 
ness.  Just  as  its  attention  is  attracted  to  its  hands,  feet,  ears,  or  umbilicus, 
so  it  is  led  to  investigate  the  genitals.  Then  too,  itching  or  tickling  sensa- 
tions, brought  out  by  inflammatory  irritation  or  by  unaccustomed  or  poorly 
fitting  clothing,  may  bring  the  hands  into  contact  with  the  genitalia.  These 
accidents  may  cause  spontaneous  erections  in  extremely  young  boys.  Not 
infrequently,  latent  sensations  may  be  aroused  by  the  manipulations  of 
older  children  or  unscrupulous  adults.  If  the  sensation  of  the  first  stimulus 
is  pleasant,  naturally  it  will  be  repeated  and  a  vicious  habit  of  improper  and 
uncontrolled  abuse  develops. 

It  is  difficult  to  form  any  definite  idea  of  the  frequency  of  masturbation. 
If  mild  degrees  of  habit  are  not  excluded  the  percentage  is  likely  to  be  too 
low  rather  than  too  high.  While,  generally  speaking,  masturbation  is  less 
common  among  girls,  it  is  rather  the  rule  than  the  exception  among  boys; 
varying,  of  course  with  age,  environment,  and  training.  Whether  mastur- 
bation is  pathologic  under  all  circumstances  is  beside  the  question:  there 
can  be  no  doubt  that  it  may  become  pathologic  in  proportion  to  the  degree 
in  which  habit  is  practiced. 

The  hold  which  it  has  upon  the  child  varies  greatly.  An  uninterrupted 
incline  leads  from  the  single  or  occasional  attempt  to  those  cases  in  which 
unbounded  abuse  reigns,  when  all  the  thoughts  and  actions  of  the  child 
become  centred  upon  the  practice  early  and  late.  The  most  unmitigated 
forms  of  abuse  are  occasionally  seen  in  girls  still  in  their  early  childhood. 

In  spite  of  the  varied  forms  in  which  it  may  appear,  masturbation  is 
easily  recognized  by  the  careful  observer.  It  is  true  that  the  physician  in 
making  a  diagnosis  is  dependent  largely  upon  the  report  of  the  persons 
constantly  in  contact  with  the  child,  who  alone  are  able  to  observe  the 
patient  at  all  times  without  attracting  the  attention  of  the  observed.  The 
hands  do  not  necessarily  play  a  part  in  masturbation.  Especially  in  girls, 
the  compression  and  friction  of  the  thigh?  is  often  sufficient.  Sometimes 
the  genital  parts  are  rubbed  against  articles  of  furniture  or  pressed  rhyth- 


DISEASES  OF  THE  GENITO-URINARY  SYSTEM          455 

mically  upon  the  bedclothes.  In  young  children  this  hardly  ever  results 
in  a  true  orgasm  or  even  in  any  actual  acme.  When  ejaculation  occurs  in 
sexually  immature  boys  the  material  consists  of  the  secretion  of  the  prostate 
of  the  urethral  gland  and  the  urethral  bulb. 

The  anxious  parents  are  interested  primarily  in  the  question  of  the  occur- 
rence and  extent  of  injuries  to  health  resulting  from  masturbation.  To  the 
physician  the  primary  question  reverses  itself;  for  excessive  masturbation  is 
not  so  much  the  cause  as  the  effect  of  psychic  abnormality.  Almost  all 
idiotic  children  and  those  with  marked  psychoses  masturbate;  and  even  in 
apparently  normal  children  excesses  may  develop  as  the  usual  result  of 
congenital  neurotic  tendency  or  of  neuropathic  stigmata.  Occasional 
masturbation  in  healthy  children  is  probably  harmless  and  surely  too  much 
stress  is  usually  laid  upon  the  practice  in  such  cases.  Major  degrees  of 
habit,  in  which  satisfaction  is  obtained  by  increasing  stimuli  and  only  with 
extreme  exertion  of  the  body  and  at  the  expense  of  the  will  may  injure  the 
nervous  system  and  apparently  affect  also  the  function  of  the  heart.  The 
extreme  influence  which  may  be  induced  over  the  psychic  conditions  of  the 
patient  as  the  result  of  overanxious  and  senseless  treatment  seem  to  the 
writer  of  much  greater  consequence.  Filled  with  the  consciousness  of  past 
errors,  tempted  to  future  wrongdoing,  frightened  by  punishment,  with 
vague  knowledge  of  the  serious  results  of  the  habit,  and  forced  into  solitude 
by  fear  and  shame,  the  masturbator  passes  from  the  pleasure  of  the  moment 
to  the  resultant  remorse  and  becomes  constantly  weaker  in  will  with  the 
renewal  of  good  resolutions  which  are  immediately  followed  by  a  repeti- 
tional  fall.  This  disturbing  inner  conflict  is  probably  the  principal  factor  in 
placing  the  stamp  upon  the  nature  of  the  masturbator.  The  picture  of  the 
flaccid,  tired,  self-centred  and  shy  melancholic  is  not  seen  in  the  years  of 
undisturbed  and  active  sexual  life. 

The  milder  forms  of  masturbation  are  overcome  in  the  course  of  years 
and  do  not  affect  normal  development.  There  is  little  hope  of  permanent 
recovery  for  severe  cases;  the  possibilities  of  therapy  are  not  very  great. 
The  affect  of  any  punishment  is  soon  exhausted  and  corporal  punishment  is 
not  without  a  directly  bad  influence.  Actually,  masturbation  can  be  pre- 
vented only  by  uninterrupted  watchfulness.  Restrictive  apparatus  or 
mechanical  devices  have  a  disadvantage,  in  that  they  continually  attract 
the  attention  which  should  rather  be  diverted  from  the  organs  involved 
(Heubner) .  This  desirable  result  can  be  achieved  only  by  wise  pedagogic 
influence  exerted  by  an  experienced  outsider.  The  child  must  be  enter- 
tained and  kept  constantly  busy  at  physical  and  mental  tasks.  Complete 
tire,  by  means  of  work,  play  and  sports,  which  serve  to  develop  the  energy 
and  strengthen  the  will,  cause  the  child  to  fall  quickly  asleep. 

Boys  should  be  taught  to  empty  the  bladder  at  night  immediately  before 
retiring  and  in  the  morning  upon  getting  up. 

NEW  GROWTHS 

In  childhood,  the  genito-urinary  organs  are  relatively  often  the  seat  of 
various  kinds  of  new  growths.  This  is  especially  true  in  early  childhood. 


456  TEXT-BOOK  OF  PEDIATRICS 

Not  uncommonly  we  find  rapidly  growing  malignant  tumors  arising  from 
the  kidney  or  the  adrenals.  Sarcomata,  carcinomata,  myxomata,  embry- 
onal round-cell  tumors  and  hypernephromata  occur.  They  may  develop 
almost  without  symptoms.  The  physician  does  not  usually  see  these  cases 
until  the  tumor  is  of  a  size  to  alter  the  shape  of  the  abdomen.  Careful 
determination  of  the  position,  origin  and  form  usually  give  information 
from  which  a  correct  diagnosis  may  be  made.  This  may  be  supported  by  the 
urinary  findings  (hematuria).  Cystic  degeneration  of  the  kidney  and  occa- 
sionally congenital  hydronephrosis  may  cause  similarly  large  tumors. 
Smaller  benign  kidney  tumors  are  more  rare. 

Tumors  may  also  develop  in  the  bladder  and  in  the  genital  organs  of 
both  sexes.  In  boys,  malignant  growths  are  found,  especially  in  the  pros- 
tate and  testes;  in  girls,  in  the  vagina  and  the  ovaries.  Treatment  rests 
with  the  surgeon. 


VII. 
DISEASES  OF  THE  NERVOUS  SYSTEM 

BY 

J.  IBRAHIM, 

Jena. 

ORGANIC  DISEASES  OF  THE  NERVOUS  SYSTEM 

I.  DISEASES  OF  THE  MENINGES 

Pachymeningitis  Hemorrhagica  Interim. — Several  cases  of  this  disease 
have  been  observed  in  infants  weakened  by  disturbances  of  nutrition, 
syphilis,  rickets  or  infections.  According  to  Rosenberg  hemorrhagic  rhinitis 
of  luetic,  diphtheritic  or  other  origin  plays  an  important  part  in  its  etiology. 
This  condition  precedes  the  pachymeningitis  by  from  two  to  four  months. 
The  connecting  link  may  be  a  thrombosis  in  the  region  of  the  cavernous 
sinus.  Symmetrical  proliferations  on  the  inner  surface  of  the  dura  over  the 
cerebral  convexities  in  the  anterior  and  middle  cranial  fossae  appear.  These 
proliferations  consist  of  fine  multiple  lamellae  which  enclose  newly  developed 
capillaries  or  sanguinolent  exudates.  Large  deposits  of  blood  or  serous 
fluid,  amounting  sometimes  to  one-fourth  of  a  Mtre,  may  gather  in  cyst- 
like  cavities  and  are  known  as  hygroma  of  the  dura  mater.  In  more  advanced 
cases  the  entire  brain  may  be  covered  with  a  thick  layer  of  exudate  resem- 
bling connective  tissue. 

The  clinical  manifestations  resemble  those  of  internal  hydrocephalus. 
Enlargement  of  the  cranium,  with  tensity  and  protrusion  of  the  fontanelle, 
may  develop  insidiously  or  acutely,  but  usually  without  the  accompani- 
ment of  fever.  All  the  symptoms  associated  with  hydrocephalus,  as  de- 
scribed in  a  later  page,  appear. 

The  fluid  withdrawn  by  lumbar  puncture  is  usually  clear  but  is  under 
supernormal  pressure.  It  may  be  of  a  brownish  color  and  slightly  hemor- 
rhagic if  the  pia  mater  has  been  damaged  and  communication  exists  with 
the  subarachnoid  space.  This  finding  is  pathognomonic  of  the  disease. 
Any  accidental  admixture  of  blood  resulting  from  the  lumbar  puncture  must 
be  excluded  as  a  matter  of  course.  If  this  accident  has  occurred,  it  is 
possible  to  clear  the  fluid  completely  by  sedimentation  or  centrifuging. 
The  ophthalmoscopic  picture  of  retinal  hemorrhage  (Goeppert),  which  is 
not  constantly  present,  however,  is  of  great  diagnostic  value.  If  it  is  not 
possible  to  remove  a  larger  quantity  of  fluid  by  lumbar  puncture  and  to  so 
relieve  the  symptoms  of  intracranial  pressure,  cranial  puncture  may  per- 
haps enlighten  the  diagnosis.  In  this  procedure  the  hemorrhagic  exudate 
spurts  out  so  soon  as  the  dura  is  entered.  The  puncture  is  made  through 
the  greater  fontanelle  and  in  doubtful  cases  serves  a  diagnostic  purpose. 

457 


458  TEXT-BOOK  OF  PEDIATRICS 

Treatment. — The  disease  is  amenable  to  treatment.  Repeated  lumbar 
punctures  with  the  evacuation  of  large  quantities  of  fluid  [50-150  c.c. 
(2-5  ounces,)  or  more],  are  to  be  recommended.  Cranial  puncture  should  be 
made  only  when  lumbar  puncture  gives  no  relief,  since  it  carries  with  it  the 
danger  of  hemorrhage.  The  subcutaneous  injection  of  sterilized  gelatine 
(20  c.c.),  coincidently  with  lumbar  puncture,  has  proved  helpful. 

2.  TUBERCULOUS  MENINGITIS* 

Tuberculous  meningitis  is  an  inflammation  of  the  soft  coverings  of  the 
brain  and  cord  developing  in  connection  with  miliary  tuberculosis  of  these 
organs.  It  is  always  a  secondary  condition. 

Etiology  and  Pathogenesis. — The  disease  is  most  common  in  early 
childhood.  It  is  of  greatest  frequency  between  the  second  and  the  fifth 
years.  In  the  first  year  of  infancy  it  is  rare.  In  childhood  tuberculous 
meningitis  is  almost  always  a  manifestation  of  general  miliary  tuberculosis. 
Children  apparently  in  blooming  health  often  fall  victims  to  this  disease.  At 
autopsy  some  latent  tuberculous  focus,  usually  in  the  form  of  a  caseated 
bronchial  or  cervical  node,  is  found  to  be  the  point  of  departure  for  the 
disease.  It  may  originate  also  from  bone  or  joint  tuberculosis.  Pulmonary 
foci  are  less  frequently  its  source,  saving  possibly  in  infancy  when  the 
bronchial  or  mediastinal  nodes  are  always  affected  too. 

In  most  instances  infection  of  the  meninges  is  probably  hematogenic  and 
is  due  to  the  rupture  of  some  tuberculous  mass  into  a  vein.  Much  more 
rarely  the  infective  agent  may  travel  through  the  lymph  channels.  Occa- 
sionally the  process  develops  by  continuity  from  some  neighboring  organ  or 
focus,  as  the  middle  ear,  the  cranial  bones,  the  vertebrae,  or  a  solitary 
tubercle  of  the  brain. 

A  number  of  factors  are  recognized  which  play  an  important  part  in 
determining  the  development  of  tuberculous  inflammation  of  the  brain 
membranes,  in  that  they  serve  as  direct  causes  of  the  spread  of  tuberculosis 
from  some  latent  focus  quiescent  up  to  the  point  of  its  appearance.  In  this 
relation  measles  and  pertussis  are  prominent.  Children  survive  these 
diseases,  but  they  do  not  make  a  complete  recovery  and  a  protracted  illness 
ensues  which  gradually  spreads  to  the  meninges. 

Moreover,  the  results  of  traumata  are  of  great  moment,  those  directly 
affecting  the  head  or  the  entire  body  being  less  important  than  those  which 
act  immediately  upon  an  existing  tuberculous  focus  and  cause  a  spread  of  the 
tubercle  bacilli.  It  is  a  well  recognized  fact  that  miliary  tuberculosis  and 
tuberculous  meningitis  not  infrequently  follow  operative  interference  upon 
tuberculous  disease  of  the  hip-joint  or  for  the  removal  of  a  caseated  cervi- 
cal lymph  node,  or  for  the  straightening  of  a  gibbous. 

Breast  feeding  confers  no  immunity  against  the  disease.  At  times  an 
increase  in  the  number  of  cases  has  been  observed  in  the  early  spring  months. 

Pathologic  Anatomy. — As  a  rule,  the  principal  seat  of  the  disease  is  found 
at  the  base  of  the  brain.  The  entire  brain  mass,  the  blood-vessels  and 

1  Known  in  older  terminology  as  basilar  meningitis,  acute  internal  hydrocephalus, 
water  on  the  brain,  etc. 


DISEASES  OF  THE  NERVOUS  SYSTEM  459 

nerve  roots  in  this  region  are  embedded  in  a  soft,  gelatinous,  grayish  or,  at 
times,  greenish  exudate.  Accompanying  this  is  a  diffuse  inflammatory 
edema  which  disappears  when  the  brain  is  removed  from  the  skull.  The 
convolutions  seem  smoothed  over  and  the  entire  brain  appears  to  be  satu- 
rated with  the  fluid  gathered  in  the  distended  ventricles.  The  tubercles, 
small,  gray  transparent  or  opaque  nodules,  are  generally  found  at  the  bifur- 
cations of  the  small  vessels  and,  as  a  rule,  are  most  numerous  in  the  sylvian 
fossa.  In  some  cases  inflamed  foci,  in  process  of  disintegration  are  found  on 
the  cortex,  constituting  a  meningo-encephalitis,  and  occasionally  a  few 
large  foci  in  the  form  of  yellow  caseated  plaques,  scattered  over  the  surface  of 
both  brain  and  meninges,  are  associated  with  the  miliary  tubercles.  Often 
solitary  tubercles  are  also  found  in  the  brain. 

Clinical  Picture  and  Course. — The  disease  usually  has  an  insidious 
beginning,  with  such  indistinctive  symptoms  as  anorexia  and  listlessness. 
At  the  same  tune  a  loss  of  weight  beyond  that  which  the  anorexia  would 
support  is  noted.  Slight  rises  of  temperature  may  be  discovered  now  and 
then,  the  child  may  cough  a  little  and  the  anxiously  observant  mother  soon 
decides  definitely  that  the  child  is  not  well.  Gradually  the  change  in  its 
demeanor  becomes  more  definite  and  may  be  recognized  even  by  the 
casual  observer.  The  child,  formerly  happy,  friendly,  and  always  ready  for 
play,  becomes  quiet,  fretful  and  morose,  looses  its  normal  desire  for  diver- 
sion, prefers  to  sit  in  dark  corners,  resting  its  head  against  the  wall  or  the 
back  of  the  chair,  and  requires  sleep  during  the  day.  It  avoids  bright  light 
and  loud  noises  and,  upon  occasion,  may  become  very  irritable  and  violent. 
In  the  child  who  ordinarily  meets  the  physician  with  active  resistance,  the 
quiet  indifferent  manner  with  which  he  permits  himself  to  be  questioned 
and  examined  may  attract  the  more  attention.  In  typical  cases  two  symp- 
toms now  appear  which  often  dictate  the  employment  of  a  physician,  viz., 
more  or  less  severe  and  constant  headache,  particularly  in  older  children, 
and  vomiting.  The  latter  may  be  active  in  character,  resembling  that  of 
gastric  disorder,  or  may  be  passive,  entirely  without  nausea,  and  independ- 
ent of  the  immediate  presence  of  food.  The  latter  type  is  the  more  signif- 
icant of  the  cerebral  nature  of  the  disease.  In  infants,  and  in  those  cases 
with  coincident  intestinal  tuberculosis,  the  stools  are  apt  to  be  dyspeptic  in 
character.  In  the  typical  course,  however,  obstipation,  persisting  perhaps 
to  the  end,  soon  sets  in. 

Even  when  these  symptoms  are  accompanied  by  only  slight  variations 
in  temperature  the  differentiation  of  the  disease  from  disturbances  of  purely 
gastro-intestinal  origin  is  often  very  difficult  at  this  early  stage.  Only  a 
careful  consideration  of  the  entire  picture  of  the  hereditary  predisposition, 
of  the  changed  demeanor,  the  loss  of  weight,  and  finally,  the  fruitfulness  of 
treatment  makes  it  at  all  possible. 

Very  soon  manifestations  of  irritation  appear,  and  of  such  a  character 
that  the  attention  of  even  the  inexperienced  observer  must  be  directed  to 
the  central  nervous  system.  Hyperesthesia  of  the  skin  and  other  sense 
organs  becomes  noticeable.  The  slightest  touch  causes  pain.  The  sensi- 
tiveness to  visual  and  auditory  stimuli  increases.  Hectic  flushes  appear  on 


460  TEXT-BOOK  OF  PEDIATRICS 

the  cheeks  and  transient  erythemata  upon  the  body.  A  distinct  dermatog- 
raphia  causes  red  spots,  remaining  for  a  long  time,  wherever  the  skin  has 
been  rubbed. 

Slight  indications  of  motor  irritability  develop  which  are  not  especially 
significant  in  themselves,  since  they  may  occur  in  any  febrile  affection. 
Grinding  of  the  teeth,  chewing  and  sucking  movements,  stereotyped 
repetitional  groping  about  the  head;  picking  at  the  lips,  the  bedclothes,  or 
the  genitals;  blinking,  and  deep  sighing  and  yawning,  are  observed  from  time 
to  time.  The  last  of  these  phenomena  may  prove  of  great  diagnostic  value. 

At  this  period  the  sensorium  is  usually  slightly  clouded.  The  patient 
becomes  soporose  but  will  still  give  rational  responses.  It  may  be  possible 
to  demonstrate  a  slight  rigidity  of  the  neck  muscles  which  is  particularly 
noticeable  when  the  head  is  bent  forward.  It  is  necessary  to  be  quite  cer- 
tain that  all  active  resistance  may  be  excluded,  making  the  test,  if  necessary, 


FIG.  112. — Tuberculous  meningitis.     General  tonic  spasm.     Involuntary  movements  of  the  left  side 
of  body.     Scaphoid  abdomen,  extreme  emaciation. 

when  the  child  is  asleep.  In  infants  the  increased  tension  and  protrusion  of 
the  fontanelle  is  demonstrable. 

Even  a  careful  examination  of  the  nervous  system  gives  but  little  definite 
information  at  this  time.  The  pupils  are  usually  narrowed;  they  react 
to  light  only  occasionally  and  dilate  again  immediately;  the  reflexes  are 
often  increased  and  at  times  unequal  upon  the  two  sides  of  the  body,  a  very 
important  finding  from  the  diagnostic  point  of  view.  Not  infrequently  a 
rigidity  of  the  entire  vertebral  column  accompanies  the  rigidity  of  the 
neck,  an  especially  prominent  symptom  in  older  children,  who,  even  at  this 
stage,  may  be  still  up  and  about.  Other  groups  of  muscles,  also,  may  be 
spastic,  in  which,  upon  repeated  examination,  a  distinct  change  of  tonus 
may  be  recognized.  Kernig  's  sign,  consisting  in  an  inability  to  sit  up  with- 
out bending  the  knee  or  to  flex  the  thigh,  to  a  right  angle  with  the  body, 
with  the  knee  straight  when  lying  down,  is  usually  distinct,  and  is  a  valuable 
aid  in  the  recognition  of  the  disease.  This  is  alike  true  of  Brudzinski's 
sign,  a  reflex  drawing  up  of  the  legs  upon  repeated  passive  flexion  of  the 
neck,  especially  valuable  as  a  diagnostic  feature  in  children  of  over  two 
years  of  age. 

At  this  stage,  the  vomiting  has  usually  stopped.    The  child  is  slightly 


DISEASES  OF  THE  NERVOUS  SYSTEM 


461 


delirious  at  night;  the  fever  remains  moderate,  \\ith  the  temperature  even 

normal  for  days  at  a  time.     Lumbar  puncture  is  entirely  justified  as  a 

diagnostic  measure  at  this  period  and  may  change  a  suspicion  to  a  certainty. 

The  cutaneous  tuberculin  reaction  of  v.   Pirquet  is  positive  in  the 


APT 

160  200  1.1 


FIG.  113. — Tuberculous  meningitis,  patient  ten  months  old.   Convergent  strabismus,  somnolence, 

vacant  stare. 

majority  of  cases,  but  as  in  other  forms  of  miliary  tuberculosis  it  is  occasion- 
ally absent. 

Manifestations  of  intracranial  pressure  gradually  become  more  notice- 
able, especially  when  they  are  caused  by  an  acute  inflammatory  hydro- 
cephalus.  Coincidentally,  or  at  a  somewhat  later  date,  paralytic  symptoms 
are  observed,  and  usually  in  the  field  of  the  cranial  nerve  supply.  Doubtless 
these  are  due,  in  the  main,  to  the  formation 
of  an  exudate  at  the  base  of  the  brain. 

The  sensorium  becomes  increasingly 
clouded.  With  eyes  widely  opened  the  child 
stares  into  vacancy,  reacts  but  little  on  call 
and  is  apparently  wholly  unconscious  of  its 
surroundings.  Occasionally,  it  may  utter  a 
loud,  piercing  scream,  the  hydrocephalic  cry, 
but  I  have  seen  a  number  of  cases  in  which 
this  often  recounted  symptom  is  absent.  The 
limbs  lie  lax,  as  though  paralyzed,  or  for  hours 
at  a  time  execute  continually  repeated,  auto- 
matic movements,  which  are  very  often  uni- 
lateral. Again  a  child  is  seen  to  maintain 
unusual  fixed  postures,  as  with  the  arms  extended  in  extreme  pronation 
with  the  hands  clenched  and  strongly  flexed.  Tremor  upon  motion  is  a 
common  symptom  at  this  stage. 

The  pulse  deserves  special  attention.  If  the  disease  is  observed  care- 
fully throughout  its  entire  course,  the  pulse  will  always  show  a  remarkable 
irregularity  and  infrequency.  Sometimes  the  pulse-rate  is  reduced  from 


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'  PIG.  114. — Tuberculous  meningitis. 
Five-year-old  girl.  Typical  condition 
of  the  pulse* 


462 


TEXT-BOOK  OF  PEDIATRICS 


140  or  160  per  minute  to  100  or  even  to  sixty.  It  is  irregular  and  often 
intermittent.  This,  as  a  symptom  of  irritation  of  the  vagus  in  consequence 
of  the  increasing  intracranial  pressure,  usually  lasts  but  a  few  days  and  is 
replaced  by  a  rapid  and  often  an  unusually  high  rate  of  pulse 

As  a  rule,  paralysis  of  the  cranial  nerves  is  first  manifested  in  the  eyes. 
An  inequality  of  the  pupils,  strabismus  and  nystagmus,  resulting  from 
involvement  of  the  abducens  or -the  motor  oculi,  are  of  earliest  appearance. 
Ptosis  of  one  or  both  lids  is  usually  coincident.  Winking  becomes  infre- 
quent and  a  mucoid  secretion  gathers  in  the  eyes.  The  facial  nerve,  also, 
may  be  involved. 

Examination  of  the  fundus  often  reveals  a  slight  hyperemia  of  the 
papilla,  and  in  older  children,  when  the  fontanelle  is  closed,  the  typical 
choked  disc  of  intracranial  pressure  is  seen.  Choroidal  tubercles  are  but 
rarely  found  upon  the  closest  examination. 

The  respiration  which  has  been  irregular  with  deep  sighing  inspirations, 


FIG.  115. — Tuberculous  meningitis.    Sopor,  ptosis,  strabismus,  scaphoid  abdomen. 


early  in  the  disease,  gradually  takes  on,  more  or  less  distinctly,  the  Cheyne- 
Stokes  type.  Long  intervals  of  rest  vary  with  superficial  and  deep  breath- 
ing. In  typical  form,  respirations  develop,  after  the  respiratory  pause,  from 
short  and  superficial  to  more  and  more  powerful  breathing  efforts  until  they 
reach  an  apex,  after  which  they  again  decline  until  another  pause  is  reached. 

Often  marked  difficulty  in  swallowing  develops  and  the  danger  of 
aspirating  food  is  imminent.  The  abdomen,  in  most  instances,  is  markedly 
retracted,  or  of  the  scaphoid  form.  Emaciation  is  extreme.  Bed-sores  are 
avoided  only  by  the  exercise  of  extreme  care,  since  the  patient  loses  control 
of  the  bowel  and  the  bladder. 

The  reflexes,  which  at  first  may  have  been  markedly  exaggerated, 
are  gradually  lost.  Similarly,  the  rigidity  of  the  neck  which,  in  infantile 
cases,  may  reach  a  very  definite  degree,  usually  disappears  before  the  end 
is  reached. 

Thus  the  patient  goes  on  to  final  dissolution,  which  usually  comes  as 
almost  a  relief  to  all  concerned.  And  yet  just  at  this  point  in  the  surely 
fatal  illness  a  deceptive  ray  of  hope  often  gleams.  Recovery  seems  about  to 


DISEASES  OF  THE  NERVOUS  SYSTEM  463 

set  in  most  unexpectedly.  The  child  suddenly  awakens  from  its  deep 
stupor,  appears  to  recognize  its  mother,  begins  to  speak,  demands  food; 
everything,  in  fact,  seems  to  indicate  the  beginning  of  improvement.  .  But 
this  false  attempt  at  recovery  lasts  only  a  few  hours  or  at  the  most  a  few 
days,  and  the  patient  again  sinks  into  the  former  condition. 

In  almost  all  cases,  clonic  epileptiform  convulsions  appear  in  the  final, 
and  sometimes  in  the  earlier  stages  of  the  disease.  The  pulse  then  jumps 
up  to  a  rate  of  180,  or  200  or  more,  per  minute  and  the  temperature  may  run 
very  high.  The  forehead  and  face  are  covered  with  a  cold  sweat ;  and  life 
ends  with  a  cardiac  paralysis,  often  in  the  midst  of  a  convulsive  attack. 

As  a  rule,  the  disease  lasts  two  or  three  weeks,  but  may  continue 
longer.  The  duration  of  its  different  stages  may  vary;  in  fact,  the  greatest 
variations  from  the  type  described  may  occur. 

Atypical  Course. — Cases  which  run  a  rapid  course  and  end  in  death 
within  a  week  are  seen.  This  type  is  especially  common  during  the  first 
two  years  of  life.  Such  a  meningitis  may  develop  as  the  last  phase  of  a 
general  tuberculosis.  Its  course  is  almost  an  afebrile  one  in  infancy.  In 
such  cases  autopsy  shows  a  condition  more  nearly  resembling  miliary 
tuberculosis  of  the  meninges  than  a  tuberculous  inflammation  of  the 
brain  membranes. 

An  atypical  onset  is  not  uncommon.  Cases  commencing  with  epilepti- 
form convulsions  of  a  frequently  unilateral  character,  or  beginning  with 
coma  which  overshadows  the  entire  disease-picture,  are  recorded.  Others 
have  been  described  repeatedly  which  show  early  monoplegia,  hemiplegia, 
or  even  crossed  hemiplegia,  with  such  other  focal  symptoms  as  aphasia. 
In  these  atypical  forms  meningo-encephalitic  plaques,  or  an  excessive 
inflammatory  edema  over  the  motor  area,  or  encephalitic  foci  of  the  cere- 
bral vertex  or  in  the  region  of  the  internal  capsule,  in  connection,  sometimes, 
with  an  arterial  thrombosis,  have  been  discovered. 

The  absence  of  obstipation  and  of  scaphoid  abdomen  is  not  uncommon 
in  cases  during  the  first  year.  The  characteristically  slow  pulse  may  also 
be  wanting.  Spinal  symptoms,  by  way  of  shooting  pains  at  the  level  of 
various  cord  segments,  are  not  unknown.  Retention  of  the  urine,  in  partic- 
ular, is  of  note.  Long  continued  remissions  extending  over  weeks  or  months, 
have  been  described  a  number  of  times,  justifying  the  suggestion  of  a  tem- 
porary recovery  and  recurrence  of  the  disease.  These  cases,  however,  are 
extremely  rare. 

Diagnosis. — At  the  onset,  the  diagnosis  may  present  very  serious  diffi- 
culties. In  the  differentiation  of  the  disease  from  simple  gastro-intestinal 
disturbances,  the  observation  of  changes  in  character  and  disposition,  and 
of  variations  in  sensory  irritability,  together  with  a  study  of  the  hereditary 
predisposition  of  the  patient,  are  of  value. 

At  a  later  stage  of  the  disease,  the  neck  sign  (page  460),  is  especially 
important,  but  is  not  pathognomonic  in  infancy.  In  older  children, 
Kernig's  sign,  the  sighing  respiration,  and  the  discovery  of  changes  in  the 
reflexes  are  important.  So  in  infants  is  the  bulging  of  the  fontanelle.  It 
should  be  remembered  that  apathy,  stupor,  and  even  irregularities  of  the 


464  TEXT-BOOK  OF  PEDIATRICS 

pulse  occur  in  severe  digestive  disturbances.  The  absence  of  dermatogra- 
phia  contraindicates  meningitis. 

Typhoid  fever  may  resemble  tuberculous  meningitis  very  closely.  Di- 
arrhoea, a  dry  red  tongue,  and  leucopenia  are  symptoms  of  typhoid.  The 
diazo-reaction  is  often  present  in  meningitis.  An  early  meningitis  may  often 
be  mistaken  for  typhoid  if  somnolence  and  meteorism  are  present  from  the 
first.  The  absence  of  rose-spots,  of  low-fever  with  severe  general  symptoms, 
and  of  leucocytosis,  indicate  meningitis,  while  the  evidence  in  its  favor 
becomes  stronger  when  the  neck  sign  is  present.  Uremia  may  have  to  be 
considered  if  the  meningitis  occurs  with  oliguria  and  nephritis. 

In  its  severe  forms  spasmophilia  may  produce  a  picture  similar  to  that 
of  meningitis,  with  spasm  of  the  neck  muscles  and  of  other  muscular  groups, 
with  variations  of  the  pupils,  eclamptic  convulsions  and  even  bulging 
of  the  fontanelle.  On  the  other  hand,  it  is  known  that  many  symptoms  of 
latent  and  manifest  spasmophilia,  the  facial  or  Chvostek  phenomenon, 
tetany,  and  carpopedal  spasm,  may  appear  in  the  course  of  tuberculous 
meningitis.  In  many  cases  the  diagnosis  can  be  made  only  by  aid  of  lum- 
bar puncture. 

Brain  tumor  may  have  to  be  considered  when  focal  symptoms  usher 
in  the  disease.  All  transitory  symptoms  argue  against  tumor. 

Pyelitis,  particularly  in  the  first  two  years  of  life,  not  infrequently 
produces  a  pseudomeningitic  picture  which  leads  to  its  contusion  with 
tuberculous  meningitis.  It  is  essential  to  examine  the  urine  in  all  doubt- 
ful cases. 

Pathognomonic  Symptoms. — In  every  case  in  which  the  diagnosis  of 
tuberculous  meningitis  must  be  considered,  two  methods  of  examination 
should  be  applied.  1.  The  ophthalmoscopic  search  for  choroidal  tubercles, 
a  search,  however,  that  is  often  made  in  vain.  2.  The  lumbar  puncture,  by 
means  of  which  one  is  enabled  not  only  to  establish  the  definite  diagnosis  of 
meningitis,  but  also  to  differentiate  its  several  types. 

In  tuberculous  meningitis  the  fluid  obtained  by  lumbar  puncture  is 
under  increased  pressure ;  it  is  clear  or  very  slightly  clouded,  or  occasionally 
opalescent,  and  carries  more  than  its  normal  content  of  protein.  If  possible, 
10-20  c.c.  of  the  fluid  should  be  allowed  to  stand  at  room  temperature,  or 
better  in  an  incubator.  Usually  a  fine  cobweb-like  fibrin  clot  is  formed 
which  may  be  spread  upon  a  slide  and  stained  by  ordinary  methods.  This 
clot  contains  cells,  chiefly  mononuclear  lymphocytes,  and  if  sufficient  care 
has  been  taken  in  its  preparation  tubercle  bacilli  can  be  found  in  the  large 
majority  of  cases  and  even  in  the  early  stages  of  the  disease.  At  times,  this 
result  is  attained  only  after  a  long  and  tedious  search.  Similar  findings  may 
be  made  from  the  centrifuged  sediment  of  the  spinal  fluid. 

The  prognosis  is  almost  inevitably  of  a  fatal  result.  Exceedingly  few 
instances  of  recovery  are  known.  The  not  infrequent  spontaneous  improve- 
ment described  in  the  course  of  the  disease  will  not  give  the  experienced 
physician  much  hope. 

The  treatment,  although  fruitless  in  most  cases,  may  accomplish  much 
in  relieving  the  severe  suffering  of  the  patient  and  the  anxiety  of  relatives. 


DISEASES  OF  THE  NERVOUS  SYSTEM  465 

The  best  care  and  the  greatest  possible  quiet  and  rest  must  be  secured. 
The  diet  requires  particular  attention  from  the  beginning.  If  the  diagnosis 
has  been  well  established  and  the  disease  progresses  uninterruptedly  it  is 
probably  more  humane  to  discontinue  all  remedies  tending  to  prolong 
suffering.  Nutrient  enemata  and  tube  feeding  should  be  used  only  during 
the  early  stages.  Regular  lumbar  puncture,  repeated  once  a  day  or  every 
other  day,  is  often  useful  in  relieving  symptoms.  A  constant,  mild  measure 
of  congestion  of  the  head,  obtained  by  placing  a  small  rubber  band  about 
the  neck  is  said  to  have  proved  helpful.  Internally,  calomel  may  be  given 
at  first  in  frequently  repeated  doses  [0.03-0.05-0.1  gram;  (grain  ss-i- 
iss),  every  hour].  The  inunction  of  the  back  of  the  neck  and  the  shaven 
occiput  with  mercurial  ointment  and  the  internal  exhibition  of  potassium 
iodide  [1.-2.  grams  (grs.  xv-xxx)  each  day],  may  be  tried,  especially  in  those 
cases  which  offer  the  slightest  suspicion  of  syphilitic  meningitis.  Daily 
painting  of  the  head  with  collodion  containing  15  to  20  per  cent,  of  iodoform 
has  also  been  recommended.  The  headache  may  be  relieved  by  an  ice-cap 
so  suspended  that  it  will  not  weigh  upon  the  head. 

When  symptoms  of  motor  irritability  become  prominent,  chloral  hy- 
drate [1  gm.  (grs.  xv),  per  rectum],  or,  if  necessary,  hypodermic  injections 
of  morphin  may  be  used. 

3.  PURULENT  MENINGITIS  (MENINGITIS  SIMPLEX) 

Purulent  meningitis  is  an  inflammation  of  the  brain  coverings  and  of  the 
brain  itself  which  may  be  produced  by  various  micro-organisms.  It  is  hardly 
ever  a  primary  disease,  being  due  either  to  direct  continuation  of  a  purulent 
process  or  to  metastatic  infection. 

Etiology  and  Pathogenesis. — The  pneumococcus  (diplococcus  lanceola- 
tus),  is  the  most  common  cause  of  purulent  meningitis,  with  the  exception 
of  the  meningococcus  producing  epidemic  meningitis  which  v>  ill  be  considered 
in  a  subsequent  section.  The  disease  may  be  caused  by  the  streptococcus, 
and,  more  rarely,  by  the  staphylococcus,  by  Cohen's  bacillus,  the  influenza, 
typhoid,  or  colon  bacilli,  or  the  bacillus  proteus  or  pyocyaneus.  These 
organisms  reach  the  meninges,  either  directly,  as  in  fractures  of  the  skull,  or 
by  infection  of  spina  bifida;  or  by  way  of  the  blood,  by  metastases,  as  when  a 
meningitis  occurs  as  a  part  of  a  general  sepsis  or  polyserositis,  or  probably  as 
a  sequela  of  lobar  pneumonia.  In  the  majority  of  instances,  however,  it 
develops  by  direct  contiguity  through  the  lymph  channels.  The  most 
common  path  of  the  infection  is  from  the  nose  through  the  cribriform  plate 
into  the  cranial  cavity.  Particularly  in  infancy,  meningitis  is  commonly 
forerun  by  a  purulent  coryza.  Second  in  order  of  frequency,  the  middle 
ear  serves  as  the  primary  focus  of  infection.  This  is  especially  true  of  otitis 
following  measles  or  scarlet  fever.  A  purulent  inflammation  of  the  men- 
inges may  also  come  from  infective  processes  in  the  orbit,  from  erysipelas  of 
the  head,  from  brain  abscess,  infected  cephalhematomata,  etc.  The  disease 
is  very  frequent  in  infancy  and  occurs  even  during  the  first  days  of  life. 

Pathologic  Anatomy. — The  purulent,  seropurulent  or  fibrinous  exudate 
is  heaviest,  as  a  rule,  over  the  convexity  of  the  brain  and  often  resembles  a 
30 


466  TEXT-BOOK  OF  PEDIATRICS 

cap.  In  meningitis  arising  from  infection  of  the  middle  ear,  the  exudate  is 
occasionally  confined  to  the  base.  There  may  be  a  coincident  thrombosis  of 
the  sinuses.  When  the  ventricles  are  filled  with  purulent  fluid  the  condition 
is  termed  pyocephalus. 

The  Clinical  Picture  and  Course. — The  onset  of  the  disease  is  usually 
sudden,  attended  by  high  fever  and  terminates  fatally  within  a  few  days. 
Occurring  in  infancy,  the  picture  is  often  completely  overshadowed  by  the 
development  of  convulsions.  In  the  intervals  between  these  early  convul- 
sions, the  child  lies  panting  and  with  face  distorted  with  pain.  Later,  more 
or  less  complete  sopor  develops,  occasionally  associated  with  persistent 
tonic  spasms.  Paralyses,  similar  to  those  which  occur  in  tuberculous 
meningitis,  and  even  symptoms  which  suggest  involvement  of  the  base  of 
the  brain,  as  inequality  of  the  pupils,  strabismus,  etc.,  may  appear.  A  sud- 
den twitching  of  the  body  when  any  part  of  the  surface  is  tapped  may  be 
very  noticeable.  The  fontanelle  is  tense  and  bulging,  while  the  rigidity  of 
the  neck  is  merely  suggested  in  some  cases  and  never  takes  a  prominent  part 
in  the  symptom-complex. 

The  older  the  patient,  the  more  nearly  do  the  symptoms  approach  those 
exhibited  in  the  adult.  Terrific  headache  and  often  torturing  thirst  are 
chief  among  these  features;  but  in  such  cases  convulsive  attacks  also  occur. 
The  picture  of  inflammation  of  the  brain  membranes  in  these  more  mature 
patients  unfolds  itself  with  great  rapidity,  but  in  the  same  order  as  the 
more  gradually  developed  symptoms  referred  to. 

Atypical  Cases. — Convulsions  may  be  entirely  absent  even  in  infants, 
and  somnolence  or  stupor  and  fever,  for  the  time  being,  may  be  the  only 
symptoms  observable.  The  disease  may  run  an  essentially  latent  course 
and  if  so,  especially  when  it  supervenes  upon  other  severe  febrile  affections, 
it  ie  very  apt  to  be  overlooked.  At  times  the  sensorium  may  rema  in  unclouded 
for  a  long  time.  A  rather  protracted  course,  extending  over  several  weeks, 
has  been  noted,  particularly  in  meningitis  due  to  an  influenzal  infection. 

The  prognosis  is  usually  clear.  A  few  children  have  survived,  but  most 
of  such  survivals  have  suffered  permanent  injuries,  in  the  way  of  deafness, 
blindness,  psychical  disturbances,  etc. 

Diagnosis. — In  infants  the  examination  of  the  fontanelle  is  important, 
for  it  remains  tense  even  in  the  intervals  between  convulsions.  Occasion- 
ally lobar  pneumonia,  especially  of  the  upper  lobe,  may  simulate  meningitis 
during  the  first  few  days  of  its  course.  Careful  examination  and  the  speed- 
ily ensuing  history  should  clear  up  the  differentiation.  Disappearance  of 
the  patellar  reflexes  indicates  pneumonia  (Pfaundler).  In  all  doubtful 
cases,  lumbar  puncture,  which  in  meningitis  yields  a  fluid  more  or  less 
clouded,  or  of  even  a  creamy  purulent  character,  containing  proteins  in 
large  quantity,  with  large  numbers  of  leucocytes,  and  in  which  the  causal 
micro-organisms  may  usually  be  demonstrated  by  ordinary  methods  of 
staining,  is  a  final  and  conclusive  test. 

Treatment. — Rest,  breast-feeding  in  infancy,  and  adequate  nourish- 
ment given  by  tube  if  necessary,  are  important.  In  older  children  the 
dietary  should  be  fluid,  non-irritating  and  in  the  form  of  milk,  soups,  and 


DISEASES  OF  THE  NERVOUS  SYSTEM  467 

fruit  juices.  The  head  should  be  cooled  by  means  of  the  ice-cap  or  by  cold 
applications.  Narcotics,  such  as  ethyl  carbamate  or  chloral  by  rectum, 
when  signs  of  serious  motor  irritability  are  present,  and  inunctions  of  the 
nape  of  the  neck  and  head  with  mercurial  ointment  are  advised.  Internally, 
potassium  iodide  may  be  tried.  The  continued  exhibition  of  hexamethy- 
lenamine,  in  doses  of  two  to  three  grams,  or  thirty  to  fifty  grains  a  day,  is 
recommended.  One-half  of  this  quantity  may  be  given  to  infants.  Hot 
baths,  once  or  twice  a  day,  are  often  given.  Repeated  lumbar  puncture 
can  be  only  beneficial.  In  pneumococcic  meningitis  this  may  be  accom- 
panied with  the  intradural  injection  of  pneumococcus  serum.  Subcutaneous, 
lumbar,  or  intradural  injections  of  optochin  (ethylhydrocuprein)  may  be 
useful  (Wolff  and  Lehmann).  In  meningitis  arising  from  infection  of  the 
middle  ear  some  hope  lies  in  operative  interference. 

4.  MENINGOCOCCUS  MENINGITIS  OR  EPIDEMIC  CEREBRO- 
SPINAL  MENINGITIS. 

Meningococcus  meningitis  is  a  purulent  inflammation  of  the  brain 
membranes,  occurring  sporadically  and  in  limited  or  widespread  epidemics. 
Early  childhood  is  particularly  liable  to  the  infection,  which  is  caused  by 
the  diplococcus  intracellularis. 

Etiology  and  Epidemiology. — Epidemics  commonly  occur  in  the  cold 
season  and  reach  their  climax  in  the  period  between  February  and  May. 
They  usually  cease  during  the  summer  months. .  Sporadic  attacks,  which 
may  well  be  considered  as  isolated  cases  in  a  very  mild  epidemic  or  endemic, 
have  the  same  seasonal  relationship.  Severe  epidemics  frequently  continue 
for  five  or  six  months.  Evidently  the  disease  is  not  spread  by  articles  with 
which  the  patient  has  come  in  contact  nor  by  direct  contagion,  but  is  spread 
by  means  of  so-called  meningococcus  carriers.  Carriers  are  understood  to 
be  persons,  who  entirely  normal  in  themselves,  or  but  slightly  affected,  as 
with  a  mild  form  of  pharyngitis,  yet  nevertheless  harbor  virulent  organ- 
isms— in  this  instance  in  the  nasopharynx.  It  has  been  shown,  by  numer- 
ous experiences,  that  close  and  long  maintained  contact  is  necessary  to 
enable  one  person  to  acquire  this  infection  from  another,  or  to  carry  it  to  a 
third  person.  The  familial  transmission  of  the  disease  by  fathers,  employed 
in  mines  or  living  in  barracks,  who  become  carriers  of  the  meningococcus 
and  infect  their  children,  is  in  point.  This  tendency  is  especially  observed 
among  families  in  restricted  circumstances.  Unhygienic  social  conditions 
play  their  part  in  the  spread  of  the  disease.  The  viability  of  the  disease 
germs  is  prolonged  in  moist  air,  although  they  perish  rapidly  when  removed 
from  the  human  body. 

Individual  predisposition  appears  to  be  a  factor  in  rhe  acquirement  of 
the  disease;  children,  especially  during  the  first  three  years,  are  extremely 
liable  to  attack.  It  is  possible  that  the  status  lymphaticus  affords  an  espe- 
cially favorable  soil. 

Pathogenesis. — Epidemic  meningitis  develops  in  the  following  manner. 
The  meningococci  first  invade  the  upper  respiratory  passages  or  the  naso- 
pharynx alone,  where  they  excite  a  pharyngitis  or  a  retronasal  angina 


468  TEXT-BOOK  OF  PEDIATRICS 

accompanied  by  a  peculiar  swelling  of  the  pharyngeal  tonsil.  Sometimes, 
again,  the  pharynx  is  spared  and  the  deeper  respiratory  passages  are 
infected.  Laryngitis,  bronchitis  or  even  pneumonia  may  develop,  the 
infection  being  transmitted  to  the  meninges  from  these  areas.  These  latter 
routes  are,  however,  of  relatively  rare  travel  by  the  meningococcus. 

Numerous  observations  made  during  recent  large  epidemics,  both  in 
Silesia  and  in  North  America,  indicate  that  infection  of  the  brain  mem- 
branes is  doubtfully  a  matter  of  direct  transmission  of  the  disease  germs 
through  the  cribriform  plate,  but  that  they  pass  into  the  blood  and  reach 
the  meninges  through  the  vascular  channels.  We  are  justified  in  regarding 
meningitis  as  the  result  of  a  frequent  and  usually  a  very  early  metastasis  of 
a  meningococcic  sepsis.  Cases  of  sepsis  of  this  type,  in  which  the  brain 
membranes  have  escaped,  have  been  recognized. 

Pathologic  Anatomy. — 'When  death  occurs  in  the  fulminant  stage  of  the 
disease  hyperemia  of  the  meninges  is  the  only  finding.  In  any  other  stage, 
a  purulent  or  mucopurulent  exudate  is  found,  distributed  variably  over  the 
outer  surface  of  the  brain  or  spinal  cord  and  without  any  characteristic 
preference  for  either  the  base  or  the  convexity.  The  pia  is  clouded  and 
edematous  even  in  the  areas  uncovered  by  pus.  The  ventricles  are  usually 
distended  and  contain  a  cloudy  inflammatory  exudate.  Typical  Gram- 
negative  diplococci  are  found  everywhere.  The  brain  and  cord  tissue, 
particularly  in  the  optic  thalamus  and  the  nerve  root  zones,  are  extensively 
involved.  In  cases  in  which  death  has  occurred  during  recovery  or  con- 
valescence, the  disappearance  of  the  purulent  exudate  has  been  noted,  but 
the  cloudiness  and  secondary  fibrous  changes  of  the  meninges  persist. 

The  Clinical  Picture. — The  clinical  picture  of  meningococcus  menin- 
gitis has  so  many  characteristic  features  that  it  is  often  possible  to  make  a 
diagnosis  without  lumbar  puncture  and  even  to  differentiate  the  type  from 
other  forms  of  meningitis. 

Its  onset,  usually  sudden,  and  attended  by  high  temperature  and  often 
by  vomiting,  soon  passes  into  the  meningeal  symptom-complex.  This 
is  distinguishable  from  that  of  other  forms  of  meningitis  by  the  exceptional 
intensity  of  motor  and  sensory  irritation,  as  seen  in  the  rigidity  of  the  neck 
and  the  vertebral  column,  by  a  marked  hyperesthesia  of  the  ?kin,  a  tender- 
ness of  the  spinal  processes  and  the  extremities,  severe  headache  and  back- 
ache and,  despite  the  severity  of  the  symptoms  in  general,  by  more  or  less 
complete  retention  of  consciousness.  It  is  marked  by  very  definite  and 
constant  variations  and  remissions  of  the  fever  and  of  the  distinctively 
meningeal  symptoms  as  well.  Even  with  an  occasional  continuance  of 
the  disease  for  weeks  or  months,  it  may  terminate  either  in  death  or  recov- 
ery. Labial  herpes  is  quite  typical  of  the  meningococcic  form  of  meningitis. 
It  appears  in  the  early  days  of  illness  in  from  one-third  to  one-half  of 
the  cases  occurring  in  children  of  over  three  years  of  age.  Often  serious 
complications,  involving  both  the  eye  and  ear,  may  accompany  or  follow 
the  disease. 

Special  Symptoms.— The  disease  is  ushered  in  suddenly  with  high 
fever,  an  intense  headache,  vomiting  and,  occasionally,  with  a  chill  or  a 


DISEASES  OF  THE  NERVOUS  SYSTEM 


469 


convulsion.  The  consciousness  is  usually  clouded  at  an  early  period.  In 
older  children  active  delirium  may  ensue.  But  rarely,  and  particularly 
among  infants,  the  onset  is  more  gradual.  The  frequency  of  herpetic  erup- 
tions in  older  children  has  already  been  mentioned. 

In  most  cases  the  sensorium  clears  up  during  the  first  week.  Long  con- 
tinued sopor  is  always  an  unfavorable  sign. 

The  temperature  curve  shows  in  the  beginning  a  series  of  staircase 
elevations,  but  later  assumes  a  more  continuous  line  broken  by  lysis,  to 
which  new  fever  periods  succeed.  These  rises  are  of  varying  height  and 
continuity,  sometimes  persisting  for  several  days,  or  longer,  and  giving  to 
the  temperature  chart  a  very  irregular  outline.  The  curve  may  even  show 
intermittent  or  remittent  phases  in  which  afebrile  intervals  of  days  are 
alternated  with  fever  periods. 

The  pulse  is  frequent  and  very  labile  even  in  convalescence.  The  respi- 
ration is  much  increased,  especially  in  infancy.  Vomiting,  after  the  first 
few  days,  occurs  only  in  older  children.  As  a  rule,  the  appetite  is  seriously 


FIG.  116. — Meningococcus  meningitis.  Six-month-old  boy.  Protracted  course. 
Repeated  attacks  of  fever.  Persistent  rapid  pulse  and  rapid  respiration.  Death 
occurred  in  extreme  emaciation  in  the  hydrocephalic  stage. 

impaired.  A  high  grade  of  cachexia,  marked  by  a  scaphoid  abdomen,  is 
common  in  protracted  cases. 

The  spleen  is  not  usually  enlarged.  Albuminuria  is  common  during  the 
first  week,  but  nephritis,  on  the  other  hand,  is  rare.  Even  with  high  fever, 
the  urine  is  light  in  color  and  abundant.  Examination  of  the  blood  often 
shows  a  distinct  neutrophilic  leucocytosis. 

The  skin  is  not  only  subject  to  herpes,  but  to  other  exanthematous 
eruptions,  sometimes  at  an  early  stage,  in  the  form  of  typical  petechia  and, 
again,  in  the  second  or  third  week,  resembling  measles  and,  more  rarely 
scarlet  fever. 

Special  Symptoms  of  the  Nervous  System. — While  convulsions  and 
paralysis  of  every  kind  may  develop,  certain  individual  symptoms  usually 
assume  a  prominence  which  enables  the  experienced  observer  to  make  the 
diagnosis.  The  rigidity  of  the  neck  is  especially  marked  in  many  cases. 
The  head  is  retracted  as  far  as  possible  and  pressed  into  the  pillow.  Every 
attempt  to  bend  it  forward  develops  definite  resistance  and  severe  pain.  In 
some  instances  the  effort  induces  tonic  or  clonic  spasms  or  trembling  of  the 
limbs.  Opisthotonos  may  so  affect  the  muscles  of  the  back  as  to  cause  the 
formation  of  a  true  arc  de  cercle.  It  must  not  be  forgotten,  however,  that 


470 


TEXT-BOOK  OF  PEDIATRICS 


the  rigidity  of  the  neck  is  not  constant  and  is  subject  to  the  same  variation 
as  are  other  symptoms  of  the  disease.  It  is  not  present  in  all  cases;  it  is 
quite  occasionally  absent  in  children  under  three  years  of  age. 

When  this  important  symptom  is  absent,  the  observation  of  other 
evidences  of  irritation  is  of  the  utmost  importance.  Among  these  an  exces- 
sive sensitiveness,  manifested  by  pain  upon  the  slightest  movement  of  any 
part  of  the  body,  is  particularly  notable.  The  legs  often  seem  to  be  espe- 
cially sensitive,  the  small  patient  screaming  whenever  they  are  lifted.  Not 
infrequently  passive  motions  are  followed  by  reflex  trembling.  In  older  chil- 
dren an  overeensitivity  to  light  and  sound  is  also  very  apparent.  Derma- 
tographia,  as  in  all  forms  of  meningitis,  is  very  prominent. 

The  reflexes  do  not  follow  any  definite  rule  of  variation.  The  skin 
reflexes  are  increased  at  first.  Kernig's  sign  (see  page  460),  is  almost 

always  present  and  in  older  children  is 
of  some  diagnostic  value.  This  is  also 
true  of  Brudzinski's  neck  sign. 

Convulsions  play  a  minor  part  in 
the  disease-picture,  excepting  at  the 
onset  of  the  attack.  General  convul- 
sions of  later  development  are  often  an 
ominous  event.  Tonic  contractions  of 
individual  muscle  groups,  twitching  of 
the  ocular  muscles  or  of  the  fibres  sup- 
plied by  the  facial  nerve,  are  of  more 
common  occurrence.  Strabismus  and 
inequality  of  the  pupils  may  come  and 
go.  Paralyses  of  the  eye  muscles  are 
rare  in  this  disease  as  compared  with 
tuberculous  meningitis.  In  fact,  other 
paralyses,  as  in  the  facial  and  hypo- 
glossal  distribution,  and  paraplegia  of 
the  legs  are  seen  only  occasionally. 
Finally,  it  must  be  remembered  that  the  fontanelle  presents  a  typical 
appearance;  it  is  tense  and  even  bulging.  In  infants  with  other  symptoms 
indistinct,  this  is  an  important  sign. 

The  fluid  obtained  by  lumbar  puncture  is  always  cloudy,  and  sometimes 
is  thick  and  purulent  or  resembling  mucus,  so  that  it  will  not  flow  from  the 
needle.  In  these  cases  the  fluid  must  be  secured  from  the  lumen  of  the 
needle.  Analysis  always  shows  an  increased  protein  content  and  usually 
gives  a  negative  Trommer's  test.  Microscopic  examination  commonly  dis- 
covers masses  of  polymorphonuclear  leucocytes ;  but  at  times  these  are  but 
few  in  number.  Occasionally  large  numbers  of  typical  biscuit-shaped 
Gram-negative  diplococci,  in  part  of  extracellular  and  in  part  of  the  pathog- 
nomonic  intracellular  type  are  found.  In  cases  progressing  toward  recover y 
the  spinal  fluid  becomes  clearer  with  each  successive  puncture,  but  months 
later  may  still  contain  leucocytes,  an  increased  amount  of  protein,  but 


FIG.  117. — Meningococcus  meningitis.  Four 
and  one-half-year-old  boy.  High  grade  fixed 
opisthotonos.  Sensorium  free  throughout. 
Kernig  present.  Emaciation.  Recovery  with 
serum  treatment. 


DISEASES  OF  THE  NERVOUS  SYSTEM  471 

rarely  meningococci.  Fibrin  forms;  in  the  fluid  only  in  the  early  stages  of 
the  disease  and  again  during  convalescence. 

Complications  and  Sequelae. — Rheumatoid,  painful  swellings  of  the 
joints,  sometimes  mono-articular  and  again  multiple,  are  among  the  benign 
complications  of  the  disease.  They  usually  disappear  spontaneously  after  a 
few  days.  Occasionally  abscess  formation  ensues. 

Complications  of  special  sense  organs  and  particularly  of  the  eye  and 
ear  are  of  frequent  occurrence  and  serious  moment.  Optic  atrophy,  kera- 
titis,  and  otitis  media  may  be  considered  true  accompaniment  of  meningitis. 
Other  and  especially  serious  coincidences  of  meningitis,  which  should  prob- 
ably be  looked  upon  as  primary  metastases  of  the  meningococcic  sepsis, 
developing  early  in  the  course  of  the  disease,  are  panophthalmia,  iritis  and 
iridocyclitis.  They  are  commonly  unilateral  and  often  cause  blindness  in 
the  affected  eye. 

An  involvement  of  the  labyrinth  of  the  ear  is  sometimes  seen  and  usually 
develops  in  the  first  week  of  the  disease.  It  occurs  even  in  mild  cases;  it 


FIG.  118. — Epidemic  cerebrospinal  meningitis,  rigidity  of  the  ueck. 

is  always  bilateral.  Its  mild  forms  cause  subjective  noises  and  phenomena 
of  dizziness;  while  in  severe  cases  complete  deafness  results  and  may  be 
responsible  in  young  children  for  deaf-mutism. 

Pleural  empyema,  endocarditis  and  pericarditis  are  rarer  complications. 
On  the  contrary,  chronic  hydrocephalus  is  a  frequent  and  a  very  significant 
sequel.  An  acute  form  of  hydrocephalus  may  be  noticeable  even  during  the 
course  of  the  meningitis.  After  the  primary  disease  has  completely  disap- 
peared and  the  spinal  fluid  is  entirely  clear  and  almost  protein-free,  the 
head  may  continue  to  enlarge  and  finally  presents  the  picture  of  a  typical 
hydrocephalus  with  eyes  directed  downward  and  inward,  with  spastic  ex- 
tremities, and  mental  retardation  and  idiocy. 

Course  and  Termination. — There  are  fulminant  forms  (meningitis 
cerebro-spinalis  siderans),  which  terminate  fatally  within  a  few  hours.  In 
these  cases,  doubtless,  one  has  to  deal  with  the  most  severe  form  of  meningo- 
coccic sepsis.  On  the  other  hand,  abortive  forms,  diagnosed  only  in  the 
midst  of  epidemics,  may  recover  in  a  few  days.  Usually  the  disease  lasts  for 
weeks  or  months  and  exhibits  the  variations  and  remissions  already  de- 
scribed. In  the  course  of  these  variations  it  will  often  be  observed  that 
changes  in  the  general  well-being  and  in  the  nervous  and  psychic  symptoms 


472  TEXT-BOOK  OF  PEDIATRICS 

do  not  always  conform  to  the  rise  and  fall  of  temperature.  Recovery  may  be 
definitely  announced  only  when  there  has  been  a  complete  subsidence  of 
fever  for  a  long  period  and  when  the  patient  has  become  psychically  normal. 
A  tendency  thereafter  to  headache,  irritability,  and  weakness  of  reasoning 
power  is  occasionally  permanent. 

In  severe  cases,  death  often  results  during  the  early  days,  but  more  com- 
monly during  the  second  and  third  weeks.  It  is  usually^  preceded  by  coma 
and  convulsions.  A  fatal  termination  may  occur,  however,  after  weeks 
or  months,  either  as  a  result  of  extreme  emaciation  and  exhaustion,  or  from 
hydrocephalus  with  its  common  symptoms  of  intracranial  pressure. 

The  meningitis  basilaris  posterior,  of  English  and  American  literature, 
probably  represents  a  protracted  form  of  meningococcic  meningitis,  occur- 
ring in  early  childhood,  in  which  severe  opisthotonos,  projectile  vomiting, 
tonic  extensor  spasms,  and  a  tendency  to  post-meningitic  hydrocephalus 
play  a  prominent  part. 

Diagnosis. — A  diagnosis  is  readily  made  only  when  the  chief  symp- 
toms are  apparent.  Of  these,  special  attention  should  be  directed  to  the 
rigidity  of  the  neck,  to  the  hyperesthesia,  the  herpes,  the  disturbances  of 
consciousness  and,  in  infants,  to  the  bulging  of  the  fontanelle  and  the  tre- 
mor induced  by  passive  motion.  If  the  diagnosis  of  meningitis  be  once 
established  it  is  usually  easy  to  differentiate  between  its  various  forms. 
Lumbar  puncture  should  be  performed  very  generally  so  soon  as  epidemic 
meningitis  is  even  suspected,  not  only  for  the  sake  of  establishing  the 
diagnosis,  but  also  to  permit  of  preparation  for  serum  therapy  should  this 
procedure  be  found  necessary. 

During  the  first  or  second  day  an  apical  pneumonia  with  meningitic 
symptoms  may  result  in  a  mistaken  diagnosis.  The  severe  nervous  phenom- 
ena, the  herpes,  and  the  intense  headache  should  obviate  contusion  with 
less  serious  gastro-intestinal  disturbances.  The  slight  enlargement  of  the 
spleen,  the  leucocytosis,  the  herpes,  if  present,  as  well  as  the  sudden  onset 
of  the  attack,  are  evidence  against  typhoid  fever.  The  rose  spots  of  typhoid 
are  of  no  value  in  the  differential  diagnosis.  Influenza  may  produce  a  very 
similar  picture,  but  the  sensorium  is  usually  clearer  and  the  hyperesthesia 
is  less  marked.  The  clouding  of  consciousness  and  the  leucocytosis  are 
points  distinguishing  meningitis  from  acute  poliomyelitis  during  the  early 
days.  The  high  fever,  the  phenomena  of  irritation,  present  even  during 
remissions,  the  bulging  fontanelle,  and  the  rigidity  of  the  neck  are  evidence 
against  the  eclampsia  of  spasmophilic  character.  Of  course  it  is  often 
possible  to  elicit  the  signs  of  spasmophilia,  the  facialis  phenomenon,  the 
high  electrical  reactions,  etc.,  even  in  children  who  are  suffering  with  cerebro- 
spinal  meningitis. 

Lumbar  puncture,  in  view  of  its  lack  of  danger  and  the  ease  of  its  per- 
formance, particularly  in  childhood,  should  never  be  neglected  in  cases  of 
possible  doubt. 

Prognosis. — The  prognosis  is  in  part  dependent  upon  the  nature  of  the 
epidemic.  Generally  the  mortality  lies  between  30  and  60  per  cent.  A 
certain  number  of  the  survivors  suffer  such  serious  permanent  injuries  as 


DISEASES  OF  THE  NERVOUS  SYSTEM  473 

deafness,  blindness,  hydrocephalus,  and  idiocy.  In  the  individual  case  it  is 
often  very  difficult  to  make  a  prognosis,  since  either  death  or  complete 
recovery  may  result  after  months  of  doubt.  Restoration  is  possible  even 
when  enlargement  of  the  head  has  become  marked.  Long  continued  uncon- 
sciousness, the  occurrence  of  convulsions  even  after  the  first  week,  hemor- 
rhages in  the  skin,  and  trismus,  are  considered  unfavorable  indications  in 
the  prognosis. 

Prophylaxis. — Parents  of  young  children  should  avoid  close  contact 
with  meningococcus  carriers.  They  should  especially  avoid  the  residences 
of,  and  the  attendants  upon,  cases  of  meningitis.  Direct  transmission  of 
the  contagion  in  hospitals  has  not  been  observed. 

Treatment. — Rest,  the  best  of  care,  and  the  maintenance  of  a  good  state 
of  nutrition  by  means  of  an  adequate  and  suitable  dietary,  are  of  the  great- 
est importance.  For  this  reason  breast-milk  is  especially  indicated  for  in- 
fants. On  account  of  the  lack  of  appetite  it  may  be  necessary  at  times  to 
feed  small  quantities  at  frequent  intervals,  thus  encouraging  the  patient 
to  eat.  It  may  be  even  necessary  to  feed  with  the  stomach-tube.  Especial 
care  should  be  directed  to  the  prevention  of  secondary  infections,  cough, 
decubitus,  etc. 

Methods  of  treatment  which  seem  to  give  reliable  results,  particularly 
in  sporadic  cases,  are  hot  baths  and  lumbar  puncture.  The  baths  should 
be  given  once  or  twice  in  the  twenty-four  hours,  after  the  first  few  days. 
They  should  be  at  a  temperature  of  from  37°-40°  C.  (98.6°-104°  F.).  The 
patient  should  remain  in  the  bath  for  ten  minutes  and  afterwards  be  kept 
warm  in  order  to  induce  perspiration.  Lumbar  puncture  may  be  done 
every  two  or  three  days.  According  to  the  degree  of  pressure,  from  twenty 
to  fifty  cubic  centimeters  should  be  withdrawn.  Of tentimes  this  procedure 
has  a  very  favorable  influence  upon  the  condition  in  general  and  partic- 
ularly upon  the  nervous  symptoms.  In  the  hydrocephalic  stage  regular 
lumbar  puncture  is  undoubtedly  of  value. 

As  a  matter  of  internal  medication,  hexamethylenamine  may  be  recom- 
mended as  a  harmless  and  probably  useful  remedy.  One  to  three  grams 
(15-45  grs.),  a  day  may  be  given  and  if  necessary  continued  for  weeks.  The 
customary  doses  of  dimethylamino-antipyrin,  of  antipyrin,  or  acetphen- 
etidin  may  relieve  the  severe  pains.  For  older  children  morphin  may  be 
used.  Analeptics,  camphor,  etc.,  may  be  necessary.  In  the  event  of  persist- 
ent vomiting,  atropin  is  to  be  advised.  Ice-bags,  ice-coils,  etc.,  often  be- 
come burdensome  or  painful  and  may  be  better  avoided. 

Serum  Treatment. — The  polyvalent  antimeningococcic  serum  is  spe- 
cific. Its  use  predicates  an  absolute  diagnosis,  confirmed  by  the  micro- 
scopic and  cultural  demonstration  of  the  meningococcus.  The  presence  of  a 
Gram  negative,  intracellular  diplococcus  in  spinal  fluid  that  gives  a  positive 
Nonne  test  and  has  a  cell  count  over  thirty  justifies  its  use.  The  demon- 
stration of  the  organism  should  later  confirm  the  findings.  The  serum  must 
be  fresh  and,  as  with  all  serum  treatment,  the  earlier  it  is  given  the  better 
the  prognosis. 

The  injection  should  be  both  intraspinally  and  intravenously.     Recent 


474  TEXT-BOOK  OF  PEDIATRICS 

experience  has  taught  that  large  doses  (60-120  c.c.)  intravenously  are  of 
great  benefit.  The  organism  has  been  demonstrated  in  smears  and  culture 
from  the  mucous  membrane  of  the  nose  and  pharynx  and  the  intravenous 
injection  clears  up  these  foci  at  once.  In  epidemics,  when  the  diagnosis 
can  be  made  early,  this  procedure  may  prevent  the  advance  of  the 
meningeal  invasion. 

Spinally  the  serum  is  given  after  as  much  spinal  fluid  as  possible  has  been 
withdrawn.  It  is  advisable  to  give  a  little  less  serum  than  the  amount  of 
fluid  removed,  so  that  the  final  pressure  is  lowered.  The  serum,  warmed  to 
body  temperature,  is  allowed  to  run  in  by  gravity.  Usually  thirty  cubic 
centimeters  twice  in  twenty-four  hours  for  six  doses,  with  60  to  120  c.c.  in- 
travenously is  sufficient.  A  second  course  may  be  given  after  twenty-four 
to  thirty-six  hours  if  the  symptoms  do  not  subside  or  if  the  organism  is  still 
demonstrable  in  the  spinal  fluid.  The  results  of  the  treatment  should  be 
carefully  checked  by  cell  counts,  bacteriologic  examination,  and  the  clinical 
course  of  the  case. 

If  only  small  amounts  of  fluid  can  be  withdrawn  from  the  spinal  canal, 
the  injection  of  the  serum  may  be  repeated  more  frequently.  Some  authors 
recommend  the  washing  of  the  spaces  by  the  injection  of  warm  physiologic 
salt  solution  under  slight  pressure  and  allowing  it  to  run  out  before  putting 
in  the  serum.  The  distention  of  the  meninges  by  the  use  of  oxygen  has 
been  .suggested.  In  small  infants,  in  whom  the  canal  is  not  easily  found  in 
repeated  puncture,  or  if  the  puncture  is  dry,  ventricular  puncture  through 
the  fontanelle  may  be  tried.  The  general  care  must  be  personally  directed. 

5.  SEROUS  MENINGITIS 

Serous  meningitis  is  an  acute  or  subacute  inflammation  of  the  pia  char- 
acterized by  the  formation  of  a  clear  serous  exudate. 

At  autopsy  only  an  edematous  flooding  of  the  meninges  and  brain  with 
the  serous  exudate,  and  the  consequences  of  such  increase  of  fluid  in  the 
flattening  of  the  convolutions  and  the  distention  of  the  ventricles,  are  noted 
as  gross  findings.  Microscopically,  inflammatory  changes  in  the  meninges 
or  in  the  choroid  plexus  or  in  the  ependyma  are  also  seen. 

The  disease  is  not  altogether  uncommon  among  infants,  but  up  to  the 
present  time  it  has  not  been  exhaustively  studied.  It  occurs  also  in  older 
children.  It  usually  develops  as  a  disease  secondary  to  pneumonia,  per- 
tussis, gastro- intestinal  disturbances,  measles,  influenza  and  other  infec- 
tions. Purulent  inflammation  of  the  middle  ear  is  regarded  as  an  important 
point  of  origin.  Probably  this  serous  meningitis  arises  from  the  invasion 
of  the  meningeal  spaces  by  very  few  non-virulent  organisms.  In  some 
instances  it  may  be  the  result  of  purely  toxic  action. 

Clinical  Symptoms  in  Infancy. — In  the  infant  a  disease-picture  may 
develop  which  is  entirely  dominated  by  fever  and  by  severe  attacks  of 
eclamptic  convulsions.  This  is  usually  the  result  of  an  acute  attack.  It  may 
terminate  rapidly  in  fulminant  form  with  hyperpyretic  temperatures 
(apoplexia  serosa).  Again  the  disease  may  begin  less  stormily;  signs  of  dis- 
turbance of  consciousness  and  intracranial  pressure  appear  more  promi- 


DISEASES  OF  THE  NERVOUS  SYSTEM  475 

nently  and  its  course  may  resemble  tuberculous  meningitis  very  closely. 
The  latter  form  probably  depends  largely  upon  ventricular  inflammation 
and  goes  by  the  name,  also,  of  acute  hydrocephalus. 

Between  these  two  opposite  types  a  number  of  transitional  forms  are 
seen.  Fever  does  not  necessarily  occur  even  in  cases  attended  by  convul- 
sions. Paralyses  do  not  play  any  very  important  part,  while  pupillary 
variations,  strabismus  and  particularly  spasms  of  the  muscles  of  the  neck 
and  limbs,  with  increased  reflexes,  are,  on  the  contrary,  frequent.  The 
convulsions  are  characterized  by  a  very  long  duration;  they  may  con- 
tinue for  hours  or  even  days.  They  are  attended  by  wild,  terrified  cries 
which  the  infant  frequently  utters.  A  careful  observation  of  the  fontanelle 
is  of  the  greatest  importance;  it  is  always  tense,  unless  the  infant  is  ex- 
tremely cachectic. 

The  fluid  obtained  by  lumbar  puncture,  an  examination  of  which  estab- 
lishes the  diagnosis,  is  usually  under  high  pressure.  It  is  clear,  but  the 
protein  content  is  definitely  increased  and  upon  standing  a  fibrin  clot  is 
formed  as  it  is  in  the  fluid  of  tuberculous  meningitis.  Microscopically  but  few 
lymphocytes  or  leucocytes  and  even  very  few  bacilli  (influenza  or  colon),  or 
cocci  (pneumo-  strepto-  or  staphylococci),  are  discovered.  A  culture  is  neg- 
ative or  shows  the  same  organisms.  Of  course,  special  precautions  must 
be  taken  to  exclude  tubercle  bacilli. 

Complications  and  Termination. — The  most  important  complication  is 
undoubtedly  spasmophilia  (tetany).  If  serous  meningitis  develops  in  a 
spasmophilic  child,  especially  in  conjunction  with  pertussis,  the  life  of  the 
patient  is  seriously  threatened  on  account  of  the  frequency  and  intensity 
of  the  convulsions  and  the  danger  of  the  coincident  hyperpyrexia.  Among 
other  diseases  chronic  disturbances  of  nutrition  notably  affect  the  pros- 
pects of  recovery. 

In  many  cases,  death  results  within  the  first  few  days.  The  fatality  is 
less  in  the  subacute  form. 

Recovery  may  be  complete,  but  the  transition  into  chronic  hydroceph- 
alus sometimes  occurs  and  more  or  less  distinct  mental  injuries  ensue, 
which  are  often  first  recognized  when  the  child  reaches  school  age.  Accord- 
ing to  Quincke,  a  tendency  to  recurrent  attacks  of  acute  exudation,  trace- 
able to  angioneurotic  causes,  may  remain  throughout  life.  These  attacks 
may  occur  in  conjunction  with  traumata,  overexertion,  excesses,  or  infec- 
tious diseases.  In  older  children,  the  symptoms  resemble  those  seen  in  the 
adult  more  and  more  closely.  A  less  distinctly  circumscribed  disease- 
picture  is  to  be  recognized,  in  which  vomiting,  headache,  intracranial  pres- 
sure symptoms,  and  visual  disturbances,  choked  disc,  optic  atrophy,  etc., 
have  a  part.  In  this  way,  the  picture  of  a  brain  tumor  which  cannot  be 
localized  may  develop,  a  condition  to  be  distinguished  from  this  disease 
only  by  the  tendency  of  the  latter  to  recovery  after  lumbar  puncture  and  by 
its  frequent  spontaneous  remissions.  Recently,  symptoms  have  been 
described  which  are  regarded  as  incident  to  an  injury  of  the  hypophysis, 
and  include  obesity  and  retarded  development  of  the  sexual  characteristics, 
(Goldstein).  In  acute  cases,  again,  the  picture  approaches  that  of  tuber- 


476  TEXT-BOOK  OF  PEDIATRICS 

culous  meningitis,  from  which  it  may  be  distinguished  only  by  its  favorable 
termination  and  by  the  absence  of  tubercle  bacilli  in  the  spinal  fluid. 

Treatment. — The  treatment  of  the  basic  disease  is  important.  This  is 
particularly  true  of  otitis  media,  if  it  be  present.  The  methods  of  treat- 
ment recommended  in  other  forms  of  meningitis,  and  particularly  the  inunc- 
tions with  mercurial  ointment,  the  hot  baths  and  the  administration  of 
hexamethylenamine  may  give  satisfactory  results.  The  most  important 
item  of  treatment  remains  in  lumbar  puncture,  which  may  need  to  be 
repeated  several  times.  In  cases  of  continued  sopor,  cold  douches  applied 
to  the  head  while  the  patient  is  in  the  hot  bath  may  prove  beneficial. 
Chloral  hydrate,  in  doses  of  0.5-1.0  gm.  (15-30  grs.),  given  per  rectum,  is 
indispensable  for  the  control  of  continuous  convulsions.  If  congenital 
syphilis  is  to  be  suspected  antiluetic  treatment  is  demanded. 

With  coincident  spasmophilia,  all  forms  of  sweat-producing  packs  are 
contraindicated,  on  account  of  the  danger  of  hyperpyrexia. 

Dietetic  treatment  of  spasmophilia,  to  be  described  later,  must  be 
instituted,  together  with  the  therapeutic  measures  already  proposed.  In 
already  existing  hyperpyrexia  energetic  hydrotherapy,  to  cooling  results, 
is  urgently  indicated. 

MENINGISM,  HYDROCEPHALOID 

Under  these  terms  are  recognized  meningitis-like  conditions  accompanying  which 
no  actual  changes  can  be  found.  They  usually  represent  a  part  of  the  symptom-com- 
plex of  so-called  intoxication  in  the  digestive  disturbances  of  infancy  (g.  v.)  In  some 
cases,  which  begin  with  high  fever,  the  results  are  probably  due  to  the  non-radiation 
of  heat,  as  in  the  so-called  summer  diarrhoeas,  while  in  older  children  they  may  be  the 
effects  of  insolation.  In  these  instances  the  fontanelle  is  not  tense,  but,  on  the  contrary, 
is  usually  sunken.  A  fuller  description  and  an  account  of  the  treatment  of  these  con- 
ditions are  given  in  the  chapter  upon  Disturbances  of  Nutrition. 

6.  THE  MENINGITIS  OP  CONGENITAL  SYPHILIS 

Congenital  syphilis  often  begins  as  a  leptomeningitis,  demonstrable  only 
by  the  microscope;  but  it  may  also  cause  an  acute  or  chronic  meningitis 
pursuing  a  course  resembling  that  of  the  serous  type,  on  the  one  hand,  or 
that  of  tuberculous  meningitis  on  the  other.  In  every  case  occurring  in  early 
childhood,  in  which  the  etiology  is  not  quite  clear,  a  course  of  treatment 
with  mercurials  and  iodides  is  urgently  indicated,  particularly  when  there 
are  other  signs  of  congenital  lues  or  when  a  positive  Wassermann  reaction 
is  obtainable. 

7.  SINUS  THROMBOSIS 

Thromboses  of  the  cranial  sinuses,  developing  usually  as  the  result  of 
general  sepsis  or  of  local  ear  infection,  do  not  differ  in  late  childhood  from 
the  course  they  take  in  the  adult.  In  infancy,  however,  septic  phlebitis  of 
the  longitudinal  sinus  causes  a  series  of  violent  symptom?,  including  high 
temperature,  coma,  jactitation,  tonic  convulsions  interrupted  by  short 
sharp  spasms,  and  tachypncea.  The  fontanelle  bulge?.  Edema  and  local 
venous  congestion  are  rare. 

Sometimes  the  diagnosis  ma;v  be  made  from  the  spinal  fluid  which  is 
brownish  or  greenish-red.  It  shows  a  reddish  sediment  upon  standing 


DISEASES  OF  THE  NERVOUS  SYSTEM  477 

consisting  of  crenated  red  blood-cells,  while  the  supernatant  fluid  remains  of 
a  yellow  or  brownish-yellow  color  (Finkelstein) .  Hemorrhagic  pachy- 
meningitis,  which  may  present  similar  characters  in  the  spinal  fluid, 
usually  gives  a  different  clinical  picture  (q.  #.).  The  disease  in  question  is 
always  fatal. 

Operative  interference  may  give  relief,  but  only  in  cases  of  otic  phlebitis. 

II.  CHRONIC  HYDROCEPHALUS 

Under  the  term  hydrocephalus  are  included  all  of  those  conditions  in 
which  a  considerably  increased  quantity  of  fluid  gathers  in  the  cranial 
cavity.  These  cases  may  differ  etiologically,  but  their  clinical  pictures 
resemble  each  other  so  closely  that  an  etiologic  diagnosis  is  oftentime 
entirely  impossible  in  any  individual  case.  A  separate  description,  there- 
fore, the  so-called  congenital  and  the  acquired  cases  will  not  be  attempted. 

1.  EXTERNAL  HYDROCEPHALUS 

External  hydrocephalus  describes  the  form  in  which  the  fluid  is  found 
outside  of  the  brain  and  beneath  the  dura  mater.  This  form  is  extremely 
rare  and  may  be  resultant  upon  hemorrhagic  pachymeningitis. 

Hydrocephalus  e  vacuo  occurs  in  cases  of  retarded  development  and 
atrophy  of  the  brain,  with  a  consequent  disproportion  between  the  cranium 
and  its  contents. 

2.  CHRONIC  INTERNAL  HYDROCEPHALUS 

In  chronic  internal  hydrocephalus,  an  increased  quantity  of  fluid  of  non- 
inflammatory origin,  gathers  in  the  distended  ventricles  of  the  brain.  It  is  a 
result  of  a  persistent  disproportion  between  the  processes  of  secretion  and 
resorption  of  the  cerebrospinal  fluid. 

Etiology  and  Pathogenesis. — The  majority  of  the  cases  of  acquired 
hydrocephalus  must  be  regarded  as  the  result  of  meningococcic  meningitis 
or,  more  occasionally,  of  serous  meningitis.  In  a  few  instances  the  accumu- 
lation of  fluid  may  be  due  to  a  blocking  of  the  outlets  consequent  upon  an 
abnormal  position  of  the  Aqueduct  of  Sylvius,  or  of  the  foramina  of  Magendie 
or  Monro.  The  not  uncommon  secondary  form  of  congestive  hydrocepha- 
lus, occurring  in  cases  of  brain  tumor  in  young  children  is  probably  due 
similarly  to  mechanical  factors.  In  this  type  compression  of  the  veins  of 
Galen  may  also  play  a  part.  In  many  a  case,  however,  no  mechanical  expla- 
nation is  possible  and  we  are  entirely  at  a  loss  to  decide  whether  it  is  a 
question  of  embarrassed  resorption  or  of  increased  secretion,  and  whether 
the  true  seat  of  the  disease  is  in  the  choroidal  vessels  or  in  the  ependyma  of 
the  ventricles.  In  so  far  as  these  cases  are  not  of  meningitic  origin,  we 
know  only  that  a  certain  number  turn  upon  a  congenital  tendency  and 
that  some  of  them  are  quite  fully  developed  even  at  birth.  Alcoholism  in 
the  progenitor  may  play  a  significant  part.  A  considerable  share  of  the 
acquired  cases  and  probably  a  notable  few  of  the  congenital  form  are  closely 
relational  to  prenatal  syphilis.  Further,  a  relationship  of  the  milder  grades 


478 


TEXT-BOOK  OF  PEDIATRICS 


of  hydrocephalus  to  rickets  is  apparently  traceable,  although  not  yet  sus- 
ceptible of  explanation. 

Pathologic  Anatomy. — The  ventricles,  as  a  rule,  are  symmetrically 
distended.  The  lateral  ventricles  are  most  markedly  affected.  They  may 
contain  from  one-fourth  to  one-half  of  a  litre  of  fluid  and  there  are  cases 
on  record  of  far  greater  quantity.  The  cerebral  hemispheres  show  the 
most  marked  changes  from  intrinsic  pressure.  In  the  more  severe  stages 
the  surface  configuration  is  progressively  obliterated,  until  the  cerebrum 
comes  to  resemble  two  soft  distended  bladders  with  very  thin  walls.  The 
central  ganglia  and  the  cerebellum  may  be  affected  by  the  compression  or 
may  be  simply  displaced.  The  floor  of  the  third  ventricle  may  protrude  like 
a  bubble  and  press  upon  the  optic  chiasm.  The  pyramidal  tracts  are  often 
injured  in  consequence  either  of  delayed  development  or  of  secondary 


FIG.  119. — Congestion  hydrocephalus  due  to  brain  tumor. 

degeneration.  Inconstantly,  the  meninges,  the  ependyma  and  the  choroid 
plexus  show  inflammatory  changes  or  their  results ;  while  still  other  abnor- 
malities are  common  in  congenital  hydrocephalus.  The  coincidence  of  the 
disease  with  spina  bifida  is  most  important. 

Clinical  Picture. — The  more  severe  grades  of  chronic  hydrocephalus, 
occurring  in  the  first  or  second  year,  usually  present  the  following  symp- 
toms: The  gigantic  head  immediately  arrests  attention.  Its  diameter, 
distinctly  exceeding  that  of  the  thorax,  may  reach  sixty  to  seventy  centi- 
meters (24-28  inches).  Large  blue  veins,  clearly  visible,  wind  over  the 
scalp,  on  which  the  hairs  are  widely  scattered,  and  are  traced  downward 
over  the  base  of  the  nose  and  the  forehead.  When  the  child  cries  these 
veins  may  swell  until  they  stand  out  in  full  relief  (Fig.  119).  The  abnormal 
and  diminutive  proportion  of  the  face  to  the  cranium  is  very  striking.  The 
face,  small  and  delicate,  suddenly  widens  at  the  level  of  the  eyes,  giving 
it  a  triangular  appearance.  The  superimposed,  massive,  dome-shaped 
cranium  gives  the  entire  head  the  form  of  a  huge  inverted  pear.  The  dis- 


DISEASES  OF  THE  NERVOUS  SYSTEM 


479 


tance  from  the  root  of  the  nose  to  the  hair  equals  the  distance  from  the 
nasion  to  the  chin.  The  bridge  of  the  nose  itself  is  wide  and  the  eyes  are 
spread.  The  auricles  are  obliquely  placed  and  the  auditory  canal  becomes 
a  fissure  running  horizontal  to  the  cranium.  The  fontanelles  are  widened 
to  the  utmost  and  the  sutures  show  as  wide  channels.  The  frontal  bone 
gapes  to  the  glabellum.  Round  eminences  appear  over  the  temples,  repre- 
senting the  lateral  fontanelles  opened  by  the  flare  of  the  bones.  The  eyes 
converge  and  appear  to  be  pushed  downward.  The  widely  distended 
pupils,  more  or  less  unreactive,  are  partially  covered  by  the  lower  lids.  A 
crescent  of  sclera  becomes  visible  between  the  upper  lid  and  the  cornea,  and 
with  its  dead  white  accentuates  an  unnatural 
stare.  The  child  is  playful  if  approached  in 
a  friendly  manner;  it  greets  its  attendants 
gleefully  and  follows  them  with  its  eyes.  In 
so  doing,  a  horizontal  nystagmus  becomes 
noticeable.  The  child  cannot  turn  the  huge 
head,  which  lies  like  a  motionless  mass  to 
which  the  small  body  is  attached. 

If  the  child  becomes  excited  it  screams 
lustily,  contorts  its  face,  and  spasms  of  the 
limbs,  often  noticeable  at  rest,  become  espe- 
cially marked  in  its  attempt  at  slight  atactic 
movements.  The  reflexes,  especially  those 
of  the  lower  limbs,  are  increased. 

The  patient  takes  nourishment  freely 
and  rapidly  and  digests  it  well,  but  almost 
always  vomits  a  part  of  one  or  two  feedings 
in  each  day. 

Special  Symptoms  and  Course. — The 
onset  of  the  disease  may  occur  at  any  age. 
By  far  the  greater  number  of  cases  are  ob- 
served during  the  first  two  years.  If  the 
large  head  has  developed  during  intra- 
uterine  life  it  may  prove  a  distinct  embar- 
rassment to  its  passage  through  the  parturient  canal.  More  often,  children, 
in  whom  a  congenital  tendency  is  really  the  cause  of  the  disease,  are  appar- 
ently normal  at  birth,  the  enlargement  of  the  head  appearing  after  an 
indefinite  period  of  faulty  development.  It  generally  sets  in,  however,  dur- 
ing the  first  year.  The  post-meningitic  forms  develop  gradually  as  a 
hydrocephalic  stage  of  epidemic  meningitis  (see  page  472).  An  increased 
protein  content  of  the  cerebrospinal  fluid  usually  points  to  an  inflammatory 
origin  in  the  early  stages  of  the  disease. 

The  enlargement  of  the  head  which,  similarly  with  an  arrest  of  growth, 
can  be  judged  only  by  regular  and  comparative  measurements  of  the  temp- 
oral and  other  cranial  dimensions,  is  usually  gradual.  There  are  cases, 
nevertheless,  in  which  a  weekly  increase  of  one  to  one-and-a-half  centi- 


FIG.  120. — Chronic  internal  hydro- 
cepha'.us,  age  ten  months.  The  condi- 
tion began  during  the  first  months  of 
life.  Nystagmus.  Pear-shaped  head. 
External  auditory  canal  at  an  angle. 
Choked  discs.  Head  is  transparent. 


480  TEXT-BOOK  OF  PEDIATRICS 

meters  (0.4  to  0.6  inch),  has  been  noted.  In  children  of  two  or  three  years 
the  fontanelles  fail  to  close  and  the  sutures  may  be  reopened. 

The  form  of  the  head  is  at  first  round  or  spherical.  In  the  more  severe 
cases,  lateral  protrusions  in  the  parietal  and  temporal  regions,  giving  the 
pear-shaped  head,  and  even  a  marked  bulging  of  the  frontal  bone  and  a 
horizontal  placing  of  the  occipital  bone  appear.  Mechanical  influences,  such 
as  continued  pressure  in  the  dorsal  position,  may  cause  asymmetrical 
alterations,  a  flattening  of  the  occiput,  etc.  The  cranial  bones  show  marked 
enlargement,  with  softened  edges  and  thin,  compressible,  parchment- 
like  centres. 

The  malposition  of  the  eyes  already  described  is  very  frequently  present, 
is  very  typical,  and  is  often  an  early  symptom.  Its  causes  have  not  been 
fully  determined.  In  many  instances,  the  flattening  of  the  bony  roof  of  the 
orbit  may  play  a  part.  Nystagmus  and  strabismus  are  common.  The 
pupils  are  generally  dilated  to  an  abnormal  degree,  but  are  rarely  unequal 
in  size.  Optic  neuritis  and  atrophy  of  the  optic  nerve  are  more  common 
results  with  increasing  years. 

Rigidity  of  the  neck,  opisthotonos,  is  not  uncommon  in  post-meningeal 
cases.  Spastic  conditions  and  exaggerated  reflexes,  especially  in  the  lower 
limbs,  are  almost  the  rule  and  may  develop  as  early  symptoms.  Adductive 
spasms,  causing  a  crossing  of  the  legs,  are  not  unusual,  but  paralyses  are  rare. 

In  the  arms,  ataxia  and  tremor  are  often  noticed  and  occasionally 
peculiar  sterotyped  positions  are  taken. 

Convulsive  attacks  of  eclamptic  quality  may  occur,  at  times,  in  very 
young  children,  but  are  not  frequent  and  may  be  absent  even  in  the  sever- 
est cases. 

The  psychic  functions  are  not  always  affected,  particularly  in  those 
milder  cases  in  which  the  head  ceases  to  enlarge.  Commonly,  however, 
mental  deficiency  or  idiocy,  in  the  most  variable  degrees,  results.  The 
powers  of  speech  and  locomotion  develop  very  late.  The  gait  is  often  spas- 
tic and  difficult. 

In  breast-fed  infants  the  physical  development  is  often  very  good,  but 
in  the  artificially-fed,  nutrition  may  be  extremely  faulty.  Vomiting  is  often 
periodic  or  of  a  recurrent  type.  Dentition  is  usually  delayed. 

As  a  rule,  the  cerebrospinal  fluid,  obtained  by  lumbar  or  ventricular 
puncture,  is  as  clear  as  water;  now  and  then  it  is  slightly  greenish  or  yellow. 
It  contains  but  little  protein,  less  than  0.1  per  cent.,  and  very  few  formed 
elements.  The  pressure  of  the  fluid  upon  lumbar  puncture  is  markedly 
increased  so  long  as  the  hydrocephalus  is  still  progressing ;  it  is  usually  over 
20.  mm.  mercury.  This  increased  pressure,  however,  only  obtains  when  the 
communication  between  the  ventricles  and  the  subarachnoid  space  remains 
open.  If  this  is  not  the  case  but  a  very  small  quantity  of  fluid  is  obtained 
and  the  tension  of  the  fontanelle  is  not  affected  by  the  withdrawal.  In  many 
instances  the  fluid  is  replaced  with  startling  rapidity  even  though  a  large 
volume,  amounting  to  250  c.c.  or  more,  has  been  removed  at  one  time. 

Termination. — Cessation  of  growth  may  occur  at  any  stage  of  the 
disease.  In  very  few  cases  may  one  speak  of  actual  recovery  since  certain 


DISEASES  OF  THE  NERVOUS  SYSTEM 


481 


physical  and  mental  weaknesses  usually  remain.  Spontaneous  recovery, 
by  evacuation  of  fluid  as  the  result  of  trauma  or  of  rupture  through  the 
nose,  eye,  or  ear,  is  extremely  rare. 

Death  commonly  results  from  intercurrent  disease  (decubital  phlegmon, 
etc.),  from  disturbances  of  nutrition,  or  even  from  operative  procedures 
which  have  been  undertaken  in  the  hope  of  relief. 

Chronic  Hydrocephalus  of  Older  Children. — A  great  bar  to  the  abnormal 
growth  of  the  cranium  is  introduced  by  the  final  closure  of  the  sutures  and 
fontanelles.  For  this  reason  alone,  hydrocephalus  presents  an  entirely 
different  clinical  picture  in  late  childhood.  Pressure  symptoms  are  much 
more  distinct  and  take  an  immediately  prominent  place.  The  entire 
cranium  may  grow  with  compara- 
tively great  rapidity  as  compared 
with  the  normal,  so  that  the  actual 
circumference  of  the  child's  head 
may  assist  the  observer 's  judgment 
materially  in  making  a  diagnosis. 
By  gradual  stages  of  development 
the  disease  is  related  to  the  serous 
meningitis  of  this  period  of  life. 

In  such  cases  as  these  the  symp- 
toms are  usually  ushered  in  by  dis- 
turbances of  sight  and  gait.  Optic 
atrophy  is  much  more  common  than 
in  infancy.  It  may  begin  with  bilat- 
eral hemianopsia  and  often  results 
in  early  blindness.  More  or  less 
severe  spasms  of  the  legs  with  exag- 
gerated patellar  and  tendo  Achillis 
reflexes  follow.  The  picture  typical 
of  Little's  disease  may  develop. 
Extremely  severe  paroxysmal  head- 
aches continuing  for  a  few  days  may 
ensue.  Dizziness,  vomiting,  tinnitus, 
paralysis  of  the  cranial  nerves  and,  more  rarely,  tremor  and  cerebellar 
ataxia  complete  the  picture.  Finally,  loss  of  memory  and  a  state  of  stupor 
supervene;  in  short,  a  history  closely  resembling  that  of  brain  tumor,  from 
which  it  maybe  distinguished  only  by  the  increased  growth  of  the  cranium 
and  by  its  tendency  to  occasional  intermissions.  Again,  the  picture  may  be 
dominated  by  epileptiform  convulsions  with  gradually  increasing  mental 
weakness,  exciting  a  suspicion  of  true  epilepsy. 

Diagnosis. — A  fully  developed  hydrocephalus  cannot  pass  unrecog- 
nized. Its  beginnings  are  often  hard  to  distinguish.  The  physician  must 
proceed  cautiously  and  avoid  frightening  the  parents  unnecessarily  by  a 
premature  diagnosis.  Not  to  fall  into  the  error  of  overlooking  a  familial  trait, 
the  parental  heads  should  be  carefully  observed.  Among  the  most  impor- 
tant early  symptoms  are  the  peculiar  position  of  the  eyes  and  the  exaggerated 
31 


FIG.  121. — Ten-year-old  boy,  healed  chronic 
hydrocephalus  arising  during  the  first  year.  Cir- 
cumference 61  cm.  (24.4  inches).  Moderate  imbe- 
cility, in  school  for  feeble-minded. 


482  TEXT-BOOK  OF  PEDIATRICS 

patellar  reflexes.  Special  precaution  is  required  in  reaching  a  diagnosis  in 
the  premature  infant,  in  whom  all  these  symptoms  may  be  present  without 
a  subsequent  development  of  hydrocephalus.  The  relative  cranial  growth 
is  always  indicative,  but  the  absolute  measurement  of  the  temporal  cir- 
cumference is  equally  important.  Normally  this  circumference  in  the 
first  month  is  55.5  cm.  (14.2  inches);  at  three  months  it  is  41  cm.  (16.4 
inches) ;  at  six  months,  43  cm.  (17.2  inches) ;  at  one  year,  46  cm.(18.4  inches) ; 
at  two  years  48  cm.  (19.2  inches) ;  at  seven  years  51  cm.  (20.4  inches) ;  and 
at  eleven  years,  53  cm.  (20.8  inches). 

In  the  diagnosis  of  congenital  hydrocephalus  the  recognition  of  other 
malformations  is  essential. 

Syphilitic  hydrocephalus  is  usually  of  moderate  degree  and  is  distin- 
guished by  ite  scaphocephalic  form.  The  Wassermann  test  should  be  taken 
in  every  case. 

Low  pressure  of  the  spinal  fluid  and  rapid  cessation  of  its  flow,  together 
with  other  symptoms  of  hydrocephalus,  indicate  obstruction  of  the  drainage 
from  the  ventricles. 

Differential  Diagnosis. — Brain  tumor,  with  hydrocephalus  due  to  con- 
gestion, frequently  escapes  diagnosis.  Early  optic  neuritis  and  especially 
optic  atrophy  in  hydrocephalus,  developing  during  the  first  year,  is  rather 
indicative  of  brain  tumor. 

The  rickitic  skull  is  more  squarely  built;  it  frequently  presents  perios- 
tea! proliferations  of  the  cranial  bones;  the  fontanelles  are  less  tense,  while 
the  actual  circumference  of  the  head  is  but  slightly  increased.  The  nervous 
symptoms  are  lacking.  Hydrocephalus,  however,  is  often  combined  with 
rickets,  not  a  surprising  fact  when  one  considers  the  frequency  of  rickets. 
Indeed  there  is  a  true  rickitic  hydrocephalus  in  which  the  cranium  never 
becomes  very  large  and  which  is  always  benign. 

Meningitis  is  distinguished  by  fever,  by  the  higher  percentage  of  pro- 
tein in  the  cerebrospinal  fluid,  and  particularly  by  the  latter 's  content  of 
fibrin  and  the  presence  in  it  of  formed  elements  and  micro-organisms.  The 
diagnostic  points  in  the  recognition  of  hemorrhagic  pachymeningitis  are 
detailed  on  page  459. 

Prognosis. — The  prognosis  in  general  is  very  bad.  Recovery  occurs 
most  frequently  in  the  luetic  and  post-meningitic  forms.  The  tendency  to 
recovery  is  best  determined  by  the  aid  of  frequent  measurements  of  the 
circumference  of  the  skull. 

Treatment. — Antisyphilitic  treatment  is  the  primary  indication  in 
every  case  of  proved  or  suspected  luetic  origin.  Mercurial  inunctions  should 
be  continued  for  weeks  and  potassium  iodide,  in  doses  of  0.25  gm.  (4  grs.)  a 
day,  for  some  months,  together  with  injections  of  salvarsan  or  neosalvarsan 
administered  in  the  customary  manner. 

Lumbar  puncture  should  be  made  regularly.  In  the  post-meningitic 
forms  of  the  disease  it  has  often  proved  useful.  It  should  be  repeated  every 
three  to  six  weeks  and  from  twenty  to  fifty  cubic  centimeters  of  fluid  should 
be  withdrawn  upon  each  occasion.  There  are  cases  in  which  it  may  be 
necessary  to  puncture  from  thirty  to  fifty  times  or  more  in  the  course  of 


DISEASES  OF  THE  NERVOUS  SYSTEM  483 

several  years.  In  two  cases  of  idiopathic  hydrocephalus  the  author  has 
secured  good  results  after  lumbar  puncture  by  compression  of  the  head  with 
a  circular  strip  of  adhesive  plaster. 

Puncture  of  the  ventricles  is  easily  accomplished  through  the  open 
fontanelles,  and  it  may  prove  necessary  if  sufficient  quantities  of  fluid  can- 
not be  withdrawn  by  lumbar  puncture. 

A  number  of  surgical  methods  have  been  devised  for  continuous  drain- 
age of  the  ventricles,  such  as  tapping  beneath  the  veins  of  Galen,  trephining 
the  occiput,  scarification  of  the  dura,  etc.  The  most  interesting  attempts 
are  those  of  Payr,  who  tried  to  establish  drainage  of  the  ventricles  by  the 
free  transplantation  of  blood-vessels  to  the  sinuses  or  veins  of  the  neck.  So 
far,  however,  all  these  attempts  at  surgical  interference  have  given  small 
satisfaction.  The  comparatively  simple  expedient  of  puncturing  the 
corpus  callosum  (Anton,  Bramann),  probably  deserves  further  trial.  If 
the  disease  is  very  far  advanced,  it  may  be  more  humane  to  undertake  no 
treatment  that  will  simply  prolong  suffering,  since  the  cerebral  functions, 
once  lost,  are  not  regained. 

Special  attention  should,  of  course,  be  given  to  the  general  care  and 
feeding  of  the  child.  The  infant  should  have  breast-milk,  if  possible.  De- 
cubitus  of  the  scalp  must  be  safeguarded  from  the  outset.  When  recov- 
ery is  in  prospect  the  motility  of  the  limbs  should  be  encouraged  by  massage 
and  warm  baths.  Imbecility  and  idiocy  may  be  unproved  by  pedagogic 
methods  of  training. 

3.  HYDRENCEPHALY 

This  term  is  applied  to  any  malformation  of  the  brain  associated  with 
hydrocephalus  e  vacuo,  and  also  to  a  peculiar  form  of  congenital  hydro- 
cephalus dependent  upon  early  interference  with  fetal  development.  In  the 
latter  form,  the  cerebral  hemispheres  are  converted  into  thin-walled  sacs, 
but  the  cranium  itself  is  little  or  not  at  all  enlarged  and  may  be  even  smaller 
than  normal  (micro-hydrencephaly).  This  condition  is  to  be  suspected 
when  the  lateral  fontanelles  are  patent  and  is  more  definitely  recognized 
when  the  head  is  translucent,  transmitting  a  red  glow  when  it  is  placed 
before  a  powerful  light  in  a  darkened  room  (Strassburger). 

III.  RETARDATION  OF  DEVELOPMENT 
1.  GROSS  MALFORMATIONS  OF  THE  BRAIN 

These  deformities  are  not  fruitful  subjects  for  discussion.  Of  the  more 
frequent  types  are  acephaly,  anencephaly,  hemicephaly,  arhinencephaly, 
cyclopia,  the  absence  of  the  corpus  callosum,  aplasia  of  the  cerebellum,  and 
parencephaly,  all  of  which  will  be  fully  described  under  the  head  of  hered- 
itary ataxia  and  the  cerebral  paralyses  of  children.  Congenital  hydro- 
cephalus and  hydrencephalus  have  been  discussed  previously.  Congenital 
idiocy  is  fully  treated  in  the  chapter  on  the  psychoses. 


484 


TEXT-BOOK  OF  PEDIATRICS 


2.  MICROCEPHALY 

Microcephalus  is  that  condition  in  which  the  size  of  the  cranium  and  of 
its  contents  remain  distinctly  below  the  normal  in  size.  Almost  invariably 

it  depends  upon  prenatal  disturbances. 
It  may  be  purely  a  matter  of  perverted 
development,  the  microcephalia  vera 
of  Giacomini,  which  includes  types 
presenting  abnormal  convolutions, 
microgyria,  and  the  like;  or  the  fetal 
brain  may  be  injured  and  atrophied  as 
the  result  of  inflammatory  or  vascular 
lesions,  a  pseudo-microcephaly.  The 
latter  form  of  microcephaly  belongs  to 
the  group  of  prenatal  brain  paralyses, 
and  will  be  mentioned  again  under  the 
head  of  cerebral  diplegias.  As  a  rule, 
cases  of  this  type  present  the  manifes- 
tations of  general  muscular  rigidity, 
with  or  without  paralysis,  athetosis, 
etc.,  while  the  true  microcephalies,  on 
the  contrary,  are  often  very  active  and 
lively.  An  extremely  high  grade  of 
idiocy,  with  a  characteristic  shape  of 
the  head,  is  common  to  both  forms. 
The  small  skull  with  retreating  fore- 
head and  particularly  large  nose  suggests  the  head  of  a  bird.  The  cranium 
may  be  normal  as  to  size  at  birth,  but  in  this  event  the  fontanelles  close 
abnormally  early  and  the  sutures  stand  out  as  prominent  ridges.  Micro- 
cephalus is  not  amenable  to  treatment. 

3.  SPINAL  EIFIDA  (RACHISCHISIS),  AND  CEPHALOCELE 

Spina  bifida  or  rachischisis  is  the  congenital  formation  of  a  fissure  in 
the  vertebral  canal  often  combined  with  a  hernia  or  protrusion  of  the 
meninges  or  of  parts  of  the  spinal  cord. 

A  spherical  or  oval  tumor  usually  lies  in  the  exact  median  line  of  the 
back.  It  may  be  sessile  or  pedunculated.  It  is  most  frequently  found  in 
the  lumbar  or  sacral  region,  but  is  occasionally  seen  in  the  neck.  It  varies 
in  size  from  that  of  a  hazel-nut  to  that  of  a  child's  head.  It  is  usually  filled 
to  distention  with  cerebrospinal  fluid.  When  the  meninges  alone  partici- 
pate in  the  hernia  it  is  termed  a  meningocele;  when  the  central  canal  widens 
at  the  point  of  the  fissure  in  the  vertebral  canal,  so  that  the  dorsal  portion 
of  the  neighboring  segments  of  the  cord  lies  in  the  sac,  a  meningo-cystocele. 
In  the  most  severe  form,  the  so-called  myelocele  or  meningomyelocele,  the 
spinal  cord  itself  is  involved  in  the  fissure  formation.  In  this  type  the  cord 
lies  open  upon  the  summit  of  the  tumor.  The  mass  presents  three  zones. 
The  first  is  a  dark  red  layer,  resembling  granulation  tissue,  lying  in  the  centre, 


FIG.  122. — True  microcephaly  (familial). 


DISEASES  OF  THE  NERVOUS  SYSTEM 


485 


the  zona  medullo-vasculosa.  This  represents  the  spinal  cord  and  from  it 
the  involved  nerves  pass  out.  Outside  of  this  lies  a  thin,  grayish,  bladder- 
like  membrane,  the  zona  epithelio-serosa,  representing  the  spinal  pia  mater. 
This,  in  turn,  is  covered  by  normal  skin,  the  zona  dermatica,  covering  the 
tumor  in  varying  thickness  from  the  base. 

Cephaloceles  are  similar  protrusions  of  the  cranial  contents  through 
circumscribed  apertures  in  the  cranium.  They  are  situated  either  on 
the  neck  or  at  the  root  of  the  nose  and  contain  prolapsed  brain.  A  ven- 
tricle of  the  brain  may  be  included  in  the  tumor,  constituting  an  en- 
cephalo-cystocele . 

Spina  bifida  anterior  consists  in  the  very  rare  formation  of  a  fissure  on 


FIQ.  123. — Spina  bifida,  meningocele.  Area  medulla-vas- 
culosa,  zona  epithelioserosa,  and  dermatica  distinctly 
bounded.  Paralysis  of  lower  extremities. 

the  ventral  wall  of  the  vertebral  canal  resulting  in  the  development  of  a 
tumor  in  the  pelvis. 

Other  malformations,  such  as  anomalies  in  the  development  of  the 
cerebellum  or  of  the  medulla  oblongata,  club-foot,  internal  hydrocephalus, 
etc.,  are  found  in  association  with  each  other  and  with  spina  bifida.  Wieland 
especially  has  called  attention  to  the  frequency  of  the  combination  of  con- 
genital apertures  of  the  cranium  with  the  tendency  to  hydrocephalus  which 
they  undoubtedly  "favor. 

Symptoms. — The  symptoms  vary  with  the  location  and  content  of  the 
tumor.  Paralysis  of  the  sphincters,  bulging  of  the  anal  region,  more  or  less 
distinct  motor  paralyses,  sensory  disturbances  and  malformations  of  the 
lower  extremities  and  even  of  the  abdominal  wall  are  frequently  en- 
countered. If  the  child  lives,  the  tumor  may  become  entirely  covered  with 


486 


TEXT-BOOK  OF  PEDIATRICS 


skin.  Death  often  occurs  during  the  first  few  weeks  as  the  result  of 
purulent  meningitis,  or  of  infections  of  the  skin,  the  urinary  passage,  etc. 
Diagnosis. — 'The  diagnosis  is  difficult  only  when  the  tumor  is  entirely 
covered  by  skin.  Lipoma,  teratoma,  or  a  tuberculous  abscess  may  also 
occur  in  the  median  line.  An  exploratory  puncture  may  be  necessary. 
In  spina  bifida  it  is  often  possible  to  feel  the  fissure  in  the  vertebral  column 
and  usually  the  hernia  may  be  partially  replaced  by  pressure. 

Treatment. — 'The  treatment  is  surgical.     It  gives  especially  brilliant 

results  in  the  type  of  pure  meningo- 
celes.  When  there  are  serious  paralyses 
present  we  render  no  service  either  to 
child  or  parents  by  the  attempt  to  pre- 
serve life.  Not  infrequently  an  internal 
hydrocephalus  arises  after  the  removal 
of  the  tumor. 

SPINA  BIFIDA  OCCULTA 

This  term  is  applied  to  those  cases  in 
which  a  tumor  does  not  present.  The 
lesion  almost  always  lies  in  the  lumbar 
region.  Its  location  is  sometimes  marked 
by  a  soft  pillow-like  bulging  and  much 
more  frequently  by  an  abnormal  growth 
of  hair.  At  other  times  its  existence  may 
be  indicated  by  scars  or  by  a  funnel-like 
depression  in  the  sacrococcygeal  region. 
In  many  cases  there  is  a  distinct  curva- 
ture of  the  spine. 

UsuaUy  diagnosis  may  be  made  by 
careful  palpation  or  in  doubtful  cases 
by  the  Roentgen  picture.    Even  when 
no  palpable  bony  aperture  exists,  mal- 
formation of  a  vertebra  and  of  the  lower 
segments  of  the  cord  may  be  found,  the 
myelo-dysplasia  of  Fuchs. 
Occasionally  club-foot  or  other  malformations  of  the  feet,  syndactylia, 
flat-foot,  etc.,  occur  coincidently  with  spina  bifida. 

The  symptoms  discernible  are  pain,  slight  symmetrical  paralyses  of  the 
feet  and,  particularly,  disturbances  of  the  sphincters  resulting,  for  instance, 
in  enuresis,  dribbling  of  urine,  and  incontinence.  Frequently,  anesthetic 
zones,  leading  to  the  formation  of  indolent  ulcers,  are  found  on  the  lower 
extremities.  Anomalies  of  the  skin  and  the  patellar  reflexes  are  usually 
observed.  Symptoms  often  do  not  appear  until  late  childhood  or  even  after 
puberty  and  are  easily  overlooked.  Their  late  appearance  is  probably  due 
to  a  persistent  strain  upon  the  tissues  intervening  between  the  spinal  cord 


FIG.  124. — Spina  bifida  occulta.     Doubling 
of  the  spinal  cord.    Club-foot. 


DISEASES  OF  THE  NERVOUS  SYSTEM 


487 


and  the  skin,  this  strain  being  due  to  the  rise  of  the  cord  in  the  vertebral 
canal  coincidently  with  the  growth  of  the  patient. 

Treatment. — 'The  operative  removal  of  the  intervening  strands  of 
tissue  and  of  compressive  fibrous  bands  which  may  be  present  is  to  be 
recommended. 

4.  HYPERTROPHY  OF  THE  BRAIN 

Hypertrophy  of  the  brain,  or  a  congenital,  abnormally  massive  and 
weighty  brain  is  a  rarity  and  is  probably  not  an  actual  disease.  It  may  pro- 
duce a  clinical  picture  resembling  that  of  chronic  hydrocephalus.  No  symp- 
toms may  be  apparent,  or  these  may  appear,  by  way  of  convulsions,  sopor, 
etc.,  only  after  the  closure  of  the  fontanelles.  The  oblique  position  of  the 


FIG.  125. — Pyrgocephalus. 

eyes,  typical  of  hydrocephalus,  is  absent.  The  finding  of  a  large  quantity 
of  cerebrospinal  fluid  upon  lumbar  puncture  contraindicates  hypertrophy 
of  the  brain. 

5.  PYRGOCEPHALY,  OXYCEPHALY 

Pyrgocephalus  (Turm  Schadel),  is  a  peculiar  deformity  of  the 
cranium  marked  by  the  steep  rise  of  the  parietal  and  occipital  bones  with 
the  formation  of  a  high  forehead.  The  entire  head  looks  as  though  it  had 
grown  upward  (see  Fig.  125),  while  the  base  of  the  skull  is  often  narrow. 
The  sutures,  and  especially  the  sagittal,  are  palpable  and  form  a  distinct 
ridge.  The  region  of  the  greater  fontanelle  is  often  particularly  prominent 
and  almost  cone-shaped.  The  pointed  head,  termed  oxycephalus,  is  a  modi- 
fication of  the  tower  head. 

The  circumference  and  size  of  the  cranium,  as  a  whole,  may  be  normal  or 
even  small.  Signs  of  rickets  are  not  inevitable.  These  peculiar  and  not 


488  TEXT-BOOK  OF  PEDIATRICS 

infrequent  malformations  of  the  head  are  often  combined  with  disturbances 
of  sight  and  exophthalmos.  Adenoid  vegetations  of  the  nasopharynx  are 
often  coincidental  with  them.  The  visual  disturbances  are  slowly  progres- 
sive. Generally,  they  do  not  become  apparent  until  the  end  of  the  first 
year,  but  they  may  suddenly  lead  to  amaurosis.  Males  are  far  more  fre- 
quently affected  by  the  disease  than  females.  Of  its  nature  we  have  no 
clear  knowledge.  The  cause  of  the  optic  atrophy  is  supposed  to  be,  in  part, 
an  increase  of  intracranial  pressure  and  in  part  a  matter  of  direct  pressure 
arising  either  from  the  abnormal  form  of  the  optic  foramen  or  from  the 
malposition  of  the  internal  carotid  which  is  pushed  into  the  posterior  part  of 
the  optic  canal  (Bohr).  Up  to  the  present  time  no  treatment  that  will 
influence  the  disease  has  been  proposed. 

6.  CONGENITAL  FUNCTIONAL  DEFECTS  OF  THE  CRANIAL  MOTOR  NERVES 

Congenital    Aplasia    of    the    Nucleus;    Absence    of    the    Nucleus; 
Infantile    Nuclear    Atrophy 

Congenital  paralyses  of  the  areas  innervated  by  the  cranial  nerves  and, 
especially,  by  the  nerves  supplying  the  eyelids,  the  facial  muscles  and 
more  rarely  the  tongue  are  seen  in  various  combinations  The  most 
frequent  of  these  is  a  uni-  or  bilateral  ptosis  and  an  abducens  paralysis. 
Tho  absence  of  the  lachrymal  secretion  has  also  been  noted  in  connection 
with  these  paralyses  The  position  of  the  ocular  bulb  is  normal  even  in 
unilateral  paralysis  of  the  abducens,  nor  does  diplopia  occur.  In  cases  of 
ptosis  it  is  often  noticed  that  the  eyelid  is  raised  when  the  mouth  is  opened. 
These  paralyses  always  remain  absolutely  stationary.  They  are  often 
observed  in  the  brothers  and  sisters  of  a  family  or  in  successive  generations 
and,  at  times,  are  associated  with  other  bodily  malformities. 

In  some  of  these  cases,  the  condition  is  one  of  aplasia  of  individual  motor 
nuclei  in  the  medulla  (Mobius,  Heubner) .  In  others,  the  defects  are  due  to 
other  causes,  dependent  either  upon  insufficient  germinal  matrices  of  the 
peripheral  nerves  or  upon  congenital  defects  of  particular  muscles,  notably 
in  the  ocular  field, 

An  early  diagnosis  is  readily  made,  but  definite  conclusions  as  to  the 
nature  of  the  disease  and  as  to  its  cause,  either  in  the  absence  of  the  nu- 
cleus or  in  muscular  aplasia,  are  hardly  ever  possible.  Nor  is  it  always 
possible  to  distinguish  from  these  the  paralyses,  particularly  of  the  facial 
nerve,  acquired  in  early  childhood  as  the  results  of  birth  traumata. 

7.   CONGENITAL  MUSCULAR   DEFECTS 

Congenital  defects  of  individual  muscles  are  not  by  any  means  infre- 
quent. The  most  common  is  a  defect  of  the  pectoralis;  the  absence  of  the 
trapezius,  the  serratus  magnus,  or  the  quadriceps  is  more  uncommon.  Some 
of  the  congenital  functional  defects  attributed  to  the  cranial  nerves,  the 
so-called  nuclear  aplasia  are  really  due  to  muscular  aplasia.  Occasionally 
one  sees  a  child  in  whom  several  muscles  may  be  absent.  In  such  a  case  it  is 
characteristically  true  that  the  missing  muscles  are  not  those  of  the  bilat- 
erally symmetric  groups.  There  are  apt  to  be  other  coincident  malfor- 


DISEASES  OF  THE  NERVOUS  SYSTEM 


489 


mations.  If  defect  of  the  pectoralis  is  present,  other  malformations  are 
often  found  in  the  arm  or  chest  on  the  affected  side,  such  as  a  congenitally 
high  shoulder,  an  aplasia  of  the  mammary  gland,  a  dystrophy  of  the  ribs, 
webbed  fingers,  etc.  As  a  rule  the  functional  failures  are  slight. 

8.  CONGENITAL  MYATONIA 

Congenital  muscular  atony,  first  described  by  Oppcnhcim,  is  character- 
ized by  a  bilateral,  symmetrical  flaccidity  and  the  partial  or  complete  ab- 
sence of  spontaneous  movements  of  the  lower  extremities,  which  lie  as 
though  affected  by  a  flaccid  paralysis.  The  joints  are  limp  and  hyperex- 
tensible.  The  arms  are  usually  less  markedly  affected  and  the  diaphragm, 
the  muscles  of  the  neck,  and  those  innervated 
by  the  cranial  nerves  in  general  are  not  com- 
monly involved.  In  some  instances  the  intelli- 
gence may  be  somewhat  retarded.  The  patellar 
reflexes  are  greatly  diminished  or  entirely 
absent;  the  limbs  are  atrophic  and  the  elec- 
trical excitability  is  reduced  quantitatively, 
even  to  an  entire  failure  of  response,  but  with 
out  giving  the  reactions  of  degeneration.  Sen- 
sation is  not  disturbed.  Gradual  improvement 
and  final  recovery  may  take  place,  but  such 
children  usually  succumb  to  some  intercurrent 
affection.  The  disorder  is  probably  one  of 
delayed  muscular  development. 

Diagnosis. — Flaccidity  of  the  limbs  and 
myopathy  of  a  rickitic  quality  must  be  taken 
into  consideration.  The  general  affection  of  all 
the  muscles  and  the  character  of  the  electrical 
reactions  make  the  exclusion  of  poliomyelitis 
and  birth  paralyses  an  easy  matter.  The 
typical  pose  of  the  upper  extremities  in  mya- 
tonia,  to  which  the  limbs  returnafterany  passive 
change  of  position,  have  been  described  many 
times  (Goelt).  This  peculiarity  may  be  taken 

into  account  in  the  difficult  differentiation  of  the  disease  from  early  infantile 
spinal  muscular  atrophy.    (Werdnig-Hofmann.) 

Treatment.— The  treatment  should  consist  in  careful  massage  and 
if  necessary  electrical  stimulation,  together  with  measures  for  the  substan- 
tial improvement  of  the  general  health.  Thyroid  preparations  may  also 
be  tried. 

IV.  DISTURBANCE  OF  THE  CEREBRAL  CIRCULATION 

Anemia  and  hyperemia  of  the  brain  do  not  exist  in  childhood  as  primary 
symptom-complexes.  When  there  is  reason  to  suspect  either  one  of  these 
errors  the  treatment  should  be  addressed  to  the  basic  disease  by  the  same 
methods  as  are  applicable  to  the  adult. 


Fio.  126. — Myatonia  congenita, 
three  and  one-half-month-old  in- 
fant. Typical  position  of  arms,  vis- 
ible insertion  of  diaphragm. 


490  TEXT-BOOK  OF  PEDIATRICS 

Fainting  spells,  which  are  rather  common  in  some  children,  may  be 
especially  mentioned.  Sometimes  they  occur  very  often  as  a  result  of  a 
neuropathic  or  hysterical  constitution. 

Chronic  hyperemia  of  the  cerebral  vessels  may  develop  as  the  result  of 
improper  methods  of  clothing,  obstipation,  the  use  of  alcohol,  habitual 
working  by  the  strong  light  of  kerosene  lamps,  etc. ;  and  it  may  disappear 
with  the  removal  of  the  cause. 

Cerebral  hemorrhages  are  very  rare  in  children.  Meningeal  hemor- 
rhages, occurring  during  the  passage  of  the  infant  head  through  the  par- 
turient canal,  are  discussed  elsewhere  under  Diseases  of  the  New-born. 
Other  forms  of  hemorrhage  are  practically  always  of  traumatic  origin  and 
present  symptoms  analogous  to  those  seen  in  the  adult.  Aside  from  condi- 
tions arising  within  the  brain  itself,  intracranial  hemorrhages  occasionally 
occur  in  infectious  diseases,  among  which  pertussis  and  purpura  are  of  the 
most  common  causal  relation.  If  the  child  escapes  death  as  the  result  of  the 
lesion,  the  consequence  may  be  the  development  of  a  spastic  infantile 
hemiplegia.  Recently,  cases  of  meningeal  hemorrhage  occurring  in  older 
children  and  followed  by  recovery  have  been  recognized.  In  these  instances, 
a  meningitic  picture  is  added  to  the  acute  symptoms  which  attend  the  lesion, 
a  condition  beneficially  influenced  by  repeated  lumbar  puncture  which 
reveals  a  hemorrhagic  spinal  fluid. 

Embolism  of  the  cranial  vessels  is  somewhat  more  common.  In  this 
event,  the  circulating  toxins  attendant  upon  the  infectious  diseases  are 
the  chief  etiologic  factors.  The  accident  occurs  most  commonly  during  or 
after  diphtheria  and  scarlet  fever,  more  rarely  after  pneumonia,  measles 
and  articular  rheumatism.  The  symptoms  resemble  those  seen  under  simi- 
lar conditions  in  the  adult ;  an  acute  apoplectiform  onset,  with  convulsions, 
sometimes  of  unilateral  character,  and  coma.  Focal  symptoms,  such  as 
aphasia,  hemiplegia  and  sensory  disturbances  follow.  Embolism  rarely 
terminates  fatally,  but  usually  leaves  a  typical  cerebral  paralysis.  Complete 
recovery  is  also  possible.  Its  differentiation  from  encephalitic  processes 
may  be  very  difficult  or  even  impossible.  The  treatment  is  similar  to  that 
of  encephalitis. 

Thrombosis  of  the  cranial  vessels  is  very  rare.  Occasionally  it  occurs 
as  a  result  of  marasmic  conditions.  Infective  sinus  thrombosis  is  discussed 
above. 

CONCUSSION  OF  THE  BRAIN  (COMMOTIO  CEREBRI) 

Concussion  of  the  brain  is  indeed  rare  as  compared  with  the  numerous 
traumata  that  affect  the  cranium  of  the  child.  It  occurs  usually  only  after 
the  first  year.  In  severe  degree  its  course  does  not  differ  from  that  in  the 
adult  and  almost  always  gives  a  good  prognosis.  Loss  of  consciousness, 
vomiting,  a  slowing  of  the  pulse,  with  later  loss  of  memory  of  the  occur- 
rences which  immediately  preceded  the  accident  are  its  chief  symptoms. 
Sometimes  transitory  aphasia  and  retention  of  the  urine  occur. 
•  The  treatment  consists  in  bodily  and  mental  rest,  the  application  of 


DISEASES  OF  THE  NERVOUS  SYSTEM  491 

ice-bags  to  the  head,  due  attention  to  the  bowels  and  the  kidneys,  cathe- 
terization  if  necessary,  and  careful  observation  of  the  heart  action. 

Mild  forms  of  concussion  are  observed  in  which  the  traumatic  origin 
may  not  be  known  or  is  discoverable  only  upon  careful  inquiry,  since 
the  patient  often  suffers  a  loss  of  memory  and  witnesses  to  the  accident 
are  apt  to  be  silenced  by  fear.  In  such  comparatively  trivial  cases,  dizzi- 
ness, headache,  apathy,  vomiting,  tremor  and  other  cerebral  symptoms  may 
appear.  Again,  rest  is  the  most  important  therapeutic  measure.  Physical 
and  mental  exertion  should  be  avoided  for  some  time  after  the  disappear- 
ance of  the  immediate  symptoms. 

Traumatic  Pseudomeningocele. — This  accident  occurs  only  in  children, 
and  to  its  occurrence  it  is  necessary  that  the  injury  to  the  cranium  cause  a 
tear  in  the  dura  as  well  as  a  fracture  or  fissure  of  the  bone.  The  appearance 
of  cerebrospinal  fluid  between  the  fragments  of  bone  and  the  scalp  follows 
usually  within  a  few  days.  Not  infrequently  a  pulsating,  distinctly  fluc- 
tuating tumor,  more  or  less  distended  with  fluid  and  covered  by  normal 
skin,  develops  gradually.  It  does  not  contain  meninges  or  brain  substance, 
although,  exceptionally,  traumatic  encephaloceles  have  been  reported. 
The  bony  fissure  at  the  base  of  the  tumor  expands  to  a  larger  opening,  with 
raised  edges  which  may  be  palpated  if  the  sac  is  not  tense.  If  the  trauma 
has  involved  simultaneously  an  injury  to  the  brain  substance  a  com- 
munication with  the  ventricles  through  the  cranial  fissure  may  be  estab- 
lished. This  is  indeed  a  fairly  frequent  occurrence.  Of  course,  in  such 
cases  paralyses,  epileptiform  phenomena,  and  other  cerebral  symptoms 
commonly  develop.  Gradual  spontaneous  repair  has  been  recorded,  but 
usually  there  is  a  tendency  to  progressive  growth. 

Diagnosis. — Cephalocele  is  congenital  and  occurs  either  at  the  root  of 
the  nose  or  in  the  cervical  region.  The  pulsation,  the  respiratory  fluctua- 
ion  of  the  swelling,  and  the  fact  that  it  can  be  reduced  by  pressure,  exclude 
cephalhematoma,  dermoid  cyst,  atheromata  and  abscess.  Unless  the  his- 
tory is  known,  it  is  more  difficult  to  exclude  cavernous  angioma  or  soft 
sarcoma  of  the  dura  which  have  eroded  the  cranial  cap.  The  temporary 
disappearance  of  the  tumor  after  lumbar  puncture  is  characteristic  of  men- 
ingocele  (Schindler). 

Treatment  is  not  very  promising.  Puncture  does  not  induce  healing  and 
may  sometimes  make  the  condition  worse.  A  cap  may  be  worn  as  a  matter 
of  protection.  A  plastic  bone  operation  to  cover  the  defect  may  be  tried. 

V.  ACUTE  ENCEPHALITIS 

Acute  encephalitis  is  an  inflammatory  disease  of  the  brain,  affecting 
chiefly  the  gray  matter.  It  is  most  frequent  in  early  childhood. 

Etiology. — Secondary  encephalitis  complicates  certain  infectious 
diseases.  It  is  especially  common  in  pertussis,  scarlet  fever,  influenza,  and 
diphtheria;  more  rarely  in  pneumonia,  typhoid,  cerebrospinal  meningitis, 
erysipelas  of  the  scalp,  or  umbilical  sepsis. 

It  is  the  result  either  of  direct  injury  by  the  specific  disease  germ,  or  of 


492  TEXT-BOOK  OF  PEDIATRICS 

the  indirect  action  of  bacterial  toxines.  A  toxic  encephalitis,  due  to  chemi- 
cal agents,  as  in  lead  poisoning,  is  also  known. 

Primary  polioencephalitis  (Strumpell),  undoubtedly  occurs  sporadic- 
ally and  at  times  epidemically,  in  the  course  of  an  outbreak  of  polio- 
myelitis (q.  v.}. 

Pathologic  Anatomy. — All  parts  of  the  brain  and  the  medulla  may  be 
affected.  Small  localized  areas  and,  more  frequently,  wide  areas  of  diffused 
inflammation  develop.  The  points  of  predilection  seem  to  be  the  basic 
ganglia  and  the  cerebral  cortex.  The  disease  is  not  confined  to  the  gray 
matter.  The  changes  first  affect  the  smaller  blood-vessels,  producing  a 
cellular  perivascular  infiltration  of  the  vessel  walls,  with  hemorrhages  and 
thromboses  and  subsequent  degenerative  changes  in  the  ganglionic  cells. 
Microscopically,  the  meninges  may  also  show  inflammatory  changes.  These 
alterations  may  be  too  minute  to  be  seen  macroscopically;  but  on  the  other 
hand,  numerous  small  yellowish  foci  or  even  hemorrhagic  spots,  the  so-called 
flea-bite  encephalitis,  may  be  visible.  In  still  other  cases,  larger  foci  of 
softening  appear,  as  a  result  of  which  considerable  sections  of  the  brain 
may  show  a  cream-like  consistency.  Such  changes  are  seen  only  in  those 
rare  cases  of  encephalitis  which  are  rapidly  fatal.  In  surviving  cases,  sub- 
sequently coming  to  autopsy,  contraction  and  sclerosis  of  the  affected 
portions  of  the  brain,  or  scars,  cysts,  and  yellow  foci  of  softening  are 
found  as  the  end  results.  Thus,  in  the  less  characteristic  final  stages  of 
the  disease,  changes  occur  which  are  scarcely  distinguishable  from  such 
purely  vascular  lesions  as  embolism,  thrombosis  or  apoplexy. 

Symptoms  and  Course. — The  onset  of  the  disease  is  usually  acute  and 
attended  with  high  fever,  convulsions  and  disturbed  consciousness.  These 
convulsions  may  take  an  eclamptic  form  or  may  have  the  quality  of  tonic 
extensor  spasms.  They  sometimes  involve  the  laryngeal  muscles  and  are 
accompanied  by  rigidity  of  the  neck.  Deep  sopor  is  usually  present  from 
the  beginning.  The  pulse-rate  is  greatly  increased,  and  respiration  is 
occasionally  of  the  Cheyne-Stokes  type.  In  pure  cases  of  polioencephalitis 
in  infancy  the  fontanelle  does  not  bulge.  The  eyes  often  show  a  persistent 
deviation  to  one  side  and  upward. 

This  serious  condition,  which  is  commonly  mistaken  for  meningitis, 
may  prove  rapidly  fatal,  but,  as  a  rule,  the  patient  survives.  Recovery  may 
occur  within  a  week  or  after  several  days.  A  great  variety  of  disturbances 
may  remain  depending,  as  to  their  nature,  upon  the  location  of  the  enceph- 
alitic  focus.  These  sequelae  are  more  fully  discussed  in  the  chapters  upon 
cerebral  paralyses  of  infants.  A  change  toward  recovery  is  usually  sig- 
nalled by  a  fairly  rapid  fall  of  temperature,  following  which  a  hemiparesis 
usually  develops.  Fever,  coma  and  paralysis  may  persist  for  weeks,  and 
focal  symptoms,  as  aphasia,  frequently  tremor,  ataxia  or  paresis  of  an  ex- 
tremity or  of  the  facial  nerve,  become  apparent  very  gradually.  Since  the 
disease  may  be  localized  in  the  pons  or  the  medulla,  a  resulting  crossed 
paralysis,  hemiplegia  alterans,  or  a  bulbar  paralysis,  is  possible.  Such  cases, 
however,  are  extremely  rare. 

The  onset  of  the  disease,  although  acute,  is  not  necessarily  abrupt.  The 
fever,  vomiting,  and  headache  may  be  mild.  The  convulsions  and  the 


DISEASES  OF  THE  NERVOUS  SYSTEM  493 

resulting  paralysis  may  be  the  chief  symptoms.  In  fact,  an  extremely 
insidious  form  of  attack  has  been  observed,  resembling  more  or  less  the 
clinical  course  of  a  brain  tumor,  in  which,  however,  the  spastic  hemiparesis 
or  the  hemiataxia  may  remain  or  disappear  entirely,  to  be  followed,  per- 
haps, by  epilepsy. 

Again,  the  course  of  the  disease  may  develop  by  a  staircase  of  exacer- 
bations, the  vomiting,  headache,  strabismus,  fainting,  or  paresis  of  one  arm, 
appearing  in  turn,  and  after  an  interval  of  days  or  a  week  the  more  turbulent 
course,  already  described,  setting  in. 

Diagnosis. — In  some  cases  it  may  be  impossible  to  distinguish  the 
disease  from  cerebral  embolism.  A  high  and  more  continuous  fever  indi- 
cates encephalitis.  Meningitis  may  be  excluded  if  increased  tensity  of  the 
fontanelle  is  lacking  and  by  the  demonstration  of  the  freedom  of  the  cere- 
brospinal  fluid  from  inflammatory  products.  Encephalitis  may  be  regarded 
as  probable  as  soon  as  focal  symptoms  and  particularly  those  of  a  hemi- 
plegic  character  appear.  Unilateral  convulsions  affecting  repeatedly  the 
same  side  are  also  of  diagnostic  value.  In  the  event  of  a  very  insidious 
course,  brain  tumor  or  cerebral  lues  is  to  be  suspected.  A  choked  disc  and 
a  progressive  development  indicate  the  former;  the  absence  of  pupillary 
reactions,  and  the  beneficial  results  of  antisyphilitic  treatment,  indicate 
the  latter.  If  the  Wassermann  reaction  is  negative  syphilis  is  improbable. 

Prognosis. — The  prognosis  is  very  bad  in  respect  of  the  fact  that  more 
or  less  severe  physical  disabilities  remain  and  that  frequently  such  psychic 
injuries  as  idiocy  and  epilepsy  follow. 

Treatment. — Rest;  the  application  of  ice-capSj  ice-water  packs,  Leiters' 
coil,  or  other  cooling  devices,  to  the  head;  and  the  complete  evacuation  of 
the  bowels  with  calomel  [0.03-0.1  gm.  (grs.  ss-iss),  every  two  hours], 
are  the  only  attempts  at  treatment  that  can  be  made  during  the  first  few 
days.  Local  and  general  blood-letting  have  been  frequently  recommended. 
One  or  two  leeches  over  the  mastoid  process  on  the  side  of  the  suspected 
focus  may  be  tried.  In  the  event  of  high  fever,  hydrotherapeutic  measures, 
assisted,  if  necessary,  by  acetylsalicylic  acid,  antipyrin  or  quinine,  given 
by  enema,  are  useful.  If  convulsions  are  long  continued  or  persistent  rest- 
lessness obtains,  chloral  hydrate,  ethyl  carbamate,  or  even  bromides  are 
recommended.  Lumbar  puncture  does  not  seem  to  have  any  favorable 
influence  upon  the  symptoms  and  should  be  employed  only  for  diagnostic 
purposes  or  in  case  the  fontanelle  is  very  tense.  The  feeding  is  a  very 
important  and  often  a  very  tedious  matter;  small  quantities  of  concen- 
trated nutriment,  frequently  given,  and  sometimes  by  means  of  the  stomach 
tube,  being  required.  It  is  hardly  necessary  to  say  that  energetic  anti- 
syphilitic  treatment  should  be  instituted  at  once  if  a  luetic  cause  is  even 
suspected.  After  the  acute  stage  of  the  disease  has  subsided,  the  treatment 
is  the  same  as  in  other  forms  of  the  cerebral  paralysis  of  childhood. 

APPENDIX 

Acute  cerebral  tremor  (Zappert),  is  a  disease  which  is  seen  in  children 
during  the  first  year  of  life.  It  occurs  more  frequently  in  boys.  It  is 
characterized  by  a  rapidly  developing  tremor  of  the  limbs  and  neck,  of 


494  TEXT-BOOK  OF  PEDIATRICS 

course  or  medium  grade,  with  which  may  be  associated  slight  spasms  and 
increased  reflexes  in  the  affected  limbs.  Unilateral  forms  have  been  de- 
scribed and  occasionally  a  slight  paresis  has  been  demonstrated  in  the  arm 
and  facial  muscles.  The  tremors  increase  markedly  upon  excitement  and 
do  not  always  cease  completely  even  in  sleep.  A  careful  study  of  the  disease 
is  essential  to  prognosis.  All  the  cases  reported  up  to  the  present  time  have 
recovered  completely  within  a  few  weeks,  although  the  mental  faculties 
were  slightly  impaired  in  a  few  instances.  The  cause  of  the  disease  is 
believed  to  lie  in  a  toxic  infective  brain  injury.  Some  authors  however, 
consider  it  a  neurosis.  In  its  etiology,  preceding  disorders  of  the  digestive 
and  respiratory  tracts,  or  certain  infectious  diseases,  such  as  measles  and 
varicella,  probably  play  a  part. 

A  diagnosis  is  usually  made  very  readily.  In  the  unilateral  forms  it  may 
be  difficult,  at  first,  to  rule  out  brain  tumor  or,  more  often,  encephalitis, 
and  all  the  more  so  since  the  disorder  very  probably  represents  a  form  of  the 
latter  disease. 

Acute  cerebral  ataxia  is  a  rare  disease.  A  general  ataxia,  without  paral- 
yses, may  appear  in  the  course  of  any  acute  infectious  disease,  such  as 
typhoid,  scarlet  fever,  measles,  etc.,  and  particularly  after  a  comatose 
stage  of  the  attack.  Associated  with  it,  occur  disturbances  of  intellec- 
tion, loss  of  memory,  monotonous  syllabic  speech  sometimes  followed  by 
aphasia,  and  exaggerated  skin  and  tendon  reflexes.  The  sensory  mech- 
anisms are  unimpaired,  with  the  exception  of  the  stereognostic  and,  occa- 
sionally, the  muscle  sense.  Such  manifestations  of  motor  irritability  as 
jerking  of  the  neck  may  be  observed.  Most  of  the  cases  recover  in  the 
course  of  a  few  weeks. 

In  their  differential  diagnosis,  polyneuritis,  in  particular,  must  be  taken 
into  account.  The  origin  of  the  disease  is  probably  an  encephalitis  and  in 
cases  showing  bulbar  and  spinal  symptoms  may  be  an  encephalomyelitis. 

VI.  EPIDEMIC  ENCEPHALITIS 

(LETHARGIC  ENCEPHALITIS,  EPIDEMIC  POLIOMYELO-ENCEPHALITIS, 
SLEEPING  SICKNESS) 

In  1917,  Economoof  Vienna,  described  a  number  of  cases  of  encephalitis 
under  the  group  name  of  "Lethargic  Encephalitis."  The  outstanding 
symptoms  of  the  group  are  paralysis  of  the  ocular  muscles  and  a  tendency 
to  sleep  or  lethargy.  Two-thirds  of  the  cases  recovered  and  about  one-third 
died.  The  pathology  of  the  disease  as  revealed  by  autopsy  was  largely 
microscopic.  The  changes  consisted  of  inflammation  of  the  gray  matter 
with,  what  v.  Economo  took  to  be,  secondary  small  cell  infiltration  about 
the  vessels.  The  destruction  of  the  ganglion  cells  as  a  result  of  neurono- 
phagia  was  regularly  observed.  Furthermore,  small  hemorrhages  in  the 
medulla  were  usually  demonstrable.  These  changes  were  usually  found 
widely  distributed  over  a  large  part  of  the  gray  matter  but  most  commonly 
and  most  intensely  in  the  region  of  the  midbrain,  the  ventricular  lining,  the 
optic  thalamus  and  the  lenticular  nucleus.  In  these  regions  the  white 
matter  was  frequently  also  affected.  These  findings  are  confirmed  in  general 


DISEASES  OF  THE  NERVOUS  SYSTEM  495 

by  later  observers.  It  has  also  been  shown  that  the  medulla  and  spinal 
cord  are  affected  in  some  cases. 

Clinical  Picture.—  The  clinical  picture  of  the  disease  is  extremely  vari- 
able. The  onset  is  usually  very  sudden  and  most  often  with  high  fever. 
The  somnolence,  which  later  in  the  disease  becomes  the  most  characteristic 
feature  of  the  symptom-complex  in  the  majority  of  the  cases,  is  not  always 
present  at  the  beginning.  In  fact,  in  children,  manifestations  of  increased 
nervous  irritability  such  as  disturbed  sleep  and  the  like,  are  more  frequent. 
In  typical  cases,  these  symptoms  are  succeeded  by  ocular  phenomena  such  as 
ptosis,  strabismus  and  double  vision.  At  times,  there  may  be  signs  of  moder- 
ate meningeal  irritation  such  as  rigidity  of  the  neck,  Kernig  's  sign,  etc.  After 
this,  the  somnolence.  In  this  state  the  child  can  be  roused,  will  answer 
questions,  is  fairly  well  oriented,  but  goes  back  to  sleep  as  soon  as  left 
alone.  This  may  persist  for  days  or  even  weeks.  The  temperature  may 
soon  fall  to  normal  and  recovery  set  in.  In  other  cases,  the  somnolence  goes 
on  to  distinct  coma  which  may  terminate  fatally  after  a  varying  period  of 
time.  There  is  a  large  group  of  symptoms,  however,  which  is  added  to  the 
above  picture.  In  some  cases,  these  additional  symptoms  are  so  prominent 
as  to  overshadow  the  symptoms  described  above,  forming  types  that  may 
be  classified  as  subgroups.  So  that  we  may  speak  of  encephalitis  of  a  cho- 
reic,  athetoid,  convulsive,  myoclonic,  catatonic,  amyostatic,  or  hemiplegic 
type.  Of  these  the  myoclonic,  rather  common  in  children,  has  especially 
peculiar  characteristics.  In  this  type,  persisting  uninterruptedly  for 
months,  individual  muscle  groups  are  subject  to  lightning-like  clonic  con- 
tractions. The  neck  muscles,  separate  groups  of  the  musculature  of  the 
extremities  and,  most  frequently,  the  abdominal  muscles  are  affected. 
The  choreic  type  may  resemble  chorea  minor  very  closely,  but  may  be 
distinguished  from  it  by  the  affection  of  the  ocular  muscles  or  by  the  appear- 
ance of  other  symptoms  not  found  in  chorea.  The  amyostatic  or  catatonic 
types  are  characterized  by  a  peculiar  rigidity  of  distinct  muscle  groups  with- 
out other  symptoms  of  disease  of  the  pyramidal  tracts,  that  is,  without 
increased  tendon  reflexes,  positive  Babinski,  etc.  They  further  show  a 
distinct  reduction  of  mobility  or  limitation  of  motion,  with  the  mask-like 
face.  Occasionally  some  tremor  may  be  added  to  this.  All  of  these  types 
may  occur  separately  in  a  single  case,  or  may  be  combined  in  various  ways. 

Lumbar  puncture  often  shows  distinct  increase  of  pressure  and  the  cell 
count  may  show  a  lymphocytosis.  The  globulin  content  of  the  fluid  may 
be  increased.  The  blood  findings  are  not  diagnostic.  A  certain  amount  of 
physical  and  mental  lethargy  may  persist  even  after  the  acute  symptoms 
have  subsided.  Pfaundler,  Hofstadt  and  others  have  called  attention  to 
the  persisting  disturbance  of  sleep.  This  symptom  is  very  common  in 
children  and  may  remain  for  six  months  or  more  after  apparent  recovery.  It 
may  not  appear  at  once,  but  set  in  gradually  several  weeks  after  the  acute 
stage.  The  patient  does  not  go  to  sleep  at  the  usual  hour  and  when  sleep 
does  come  it  is  disturbed  by  constant  thrashing  about  in  bed,  talking, 
gritting  of  teeth,  and  even  tearing  the  bedclothes.  Usually,  restful  slumber 
comes  on  in  the  early  hours  of  the  morning  and  the  child  wants  to  sleep  the 


496  TEXT-BOOK  OF  PEDIATRICS 

entire  forenoon.  Even  so,  they  lose  many  hours  of  sleep  with  the  usual  ill 
effect  upon  the  general  well-being. 

Etiology. — 'The  question  of  etiology  is  still  open  to  much  study.  Several 
authors  have  described  micro-organism  but  none  of  these  works  have  been 
confirmed.  At  present,  the  bacteriologic  findings  rest  upon  a  filterable 
virus  and  the  presence  of  globoid  bodies  in  the  lesions.  The  relation 
between  encephalitis  and  influenza  is  generally  regarded  as  a  coincidence. 
Much  work  has  been  done  to  prove  the  relation  between  encephalitis  and 
poliomyelitis.  Both  of  these  conditions  may  attack  any  part  of  the  central 
nervous  system.  Poliomyelitis  is  more  distinctly  a  disease  of  childhood  and 
encephalitis  more  commonly  a  disease  of  adult  life.  The  author  sees  a 
special  significance  in  the  apparent  absence  of  contagion  in  encephalitis. 
While  the  disease  occurs  in  epidemics,  there  is  very  little  record  of  its 
direct  transmission. 

Diagnosis.— The  differentiation  from  meningitis  may  present  some 
difficulty  in  the  early  stages.  In  infants,  it  may  be  confused  with  spasmo- 
philia  and  even  with  acute  disturbances  of  nutrition. 

Treatment. — Up  to  the  present,  the  treatment  has  been  very  meagre. 
Hexamethylene,  subcutaneous  injection  of  foreign  protein  and  other  things 
have  been  tried  without  result.  The  intravenous  or  intramuscular  injection 
of  convalescent  serum  gives  promise  of  some  help.  The  post-encephalitic 
disturbance  of  sleep  is  also  most  intractable.  Hofstadt  recommends  hot  dry 
packs,  continued  for  long  periods,  and  completely  immobilizing  the  patient. 

VII.  BRAIN  ABSCESS;  PURULENT  ENCEPHALITIS 

Brain  abscess  is  not  wholly  unknown  among  children,  or  even  in  infancy. 
It  is  a  localized  purulent  dissolution  of  the  brain  tissue,  always  of  infectious 
origin,  and  of  streptococcic,  staphylococcic,  pneumococcic,meningococcic; 
or  pyocyaneal  type.  Multiple  abscesses  are,  usually  the  results  of  metas- 
tasis in  the  course  of  bronchiectasis,  pulmonary  gangrene,  etc.  The  most 
important  form  developing  in  childhood  is  the  otogenous  abscess.  Trau- 
matic abscess  may  also  occur  and  is  usually  situated  in  the  cerebrum. 
Months  and  even  years  may  elapse  between  the  causative  trauma  and  the 
active  manifestations  of  abscess.  The  recognition  of  this  long  latency  and 
the  fact  that  fever  may  be  entirely  absent  are  important  points  in  the  diag- 
nosis. Indeed  the  clinical  picture  of  brain  abscess  resembles  that  of  brain 
tumor  so  closely  that  only  by  attention  to  the  etiologic  factor  of  possible 
injury  to  the  head  or  of  a  chronic  otitis  media  will  the  observer  keep  upon 
the  right  path. 

Otogenous  brain  abscess  develops  from  chronic  otitis  and  particularly 
from  those  forms  which  are  complicated  with  disease  of  the  mastoid  cells 
or  with  the  formation  of  cholesteatoma.  In  this  type  also,  a  latent  stage, 
often  extending  over  weeks  or  months,  is  the  common  rule.  During  this 
period  of  latency  there  exist,  at  most,  only  an  indefinite  impairment  of  the 
general  health.  The  stage  of  active  development  sets  in  quite  rapidly  and  is 
characterized  by  intense  headache,  vomiting  and  disturbances  of  the  sen- 
sorium.  The  latter  may  be  of  any  degree  of  severity,  from  mere  loss  of 


DISEASES  OF  THE  NERVOUS  SYSTEM  497 

memory  and  inability  to  concentrate  the  attention,  to  a  definite  stupor  or 
sopor.  Delirium,  like  the  headache,  of  unusual  intensity,  is  not  at  all  uncom- 
mon. Sometimes  particularly  painful  areas  over  the  cranium  may  be 
outlined  by  percussion.  These  may  be  of  value  in  determining  the  localiza- 
tion of  the  abscess.  Even  at  this  period  there  is  often  an  absence  of  fever. 
A  slow  pulse  is  usually  a  marked  feature. 

To  these  general  disturbances,  focal  symptoms  are  added  in  many 
cases.  These  are  of  the  greatest  importance  as  guides  to  the  topographic 
diagnosis  and  treatment.  An  otogenous  abscess  is  situated  either  in  the 
temporal  lobe  or  in  the  cerebellum.  In  abscess  of  the  temporal  lobe,  espe- 
cially upon  the  left  side,  a  sensory  aphasia  or  word-deafness  has  been  fre- 
quently observed,  as  well  as  a  crossed  paresis  of  the  facial  nerve  distribution 
or  of  the  extremities  as  results  of  pressure  upon  neighboring  nuclei.  An 
abscess  of  the  cerebellum  causes  intense  pain  in  the  occiput  and,  eventually, 
opisthotonos,  vomiting,  dizziness  and  an  atactic  gait  and  pose.  Secondary 
effects,  by  way  of  crossed  paralyses  of  the  extremities  and  the  most  variable 
pareses,  result  from  pressure  upon  the  medullary  centres  or  upon  nerve 
roots  arising  from  them. 

Meningitis  may  be  excluded  by  lumbar  puncture.  In  the  differentiation 
from  brain  tumor,  the  history  of  possible  etiologic  factors,  the  continuing 
presence  of  otitis,  the  development  of  focal  conditions  in  the  temporal  lobe 
or  in  the  cerebellum,  are  of  especial  importance.  Neisser's  brain  puncture 
may  sometimes  establish  a  diagnosis.  In  doubtful  cases  operation,  which 
in  so  large  a  number  of  brain  abscesses  results  in  complete  recovery,  should 
always  be  advised. 

VIII.  CEREBRAL  TUMOR 

The  clinical  picture  of  brain  tumor  in  childhood  is  quite  similar  to  that 
in  the  adult.  For  this  reason  we  shall  merely  touch  upon  a  few  points  of 
special  interest  from  the  viewpoint  of  the  pediatrist. 

Brain  tumors  are  fairly  common  among  children  and  especially  during 
the  first  years  of  life.  Brain  tubercles  are  of  most  frequent  occurrence  and 
their  usual  location  is  the  cerebellum.  Gliomata  come  next  in  fre- 
quency. Tumors  of  this  type  diffusely  infiltrate  variably  large  areas  of  the 
brain  tissue,  without  being  sharply  circumscribed  from  the  surrounding 
normal  structures.  They  are  often  found  in  the  pons  but  they  may  occur 
in  the  cerebrum  or  cerebellum.  Sarcomata,  myomata,  angiomata,  and 
cysticercus  cysts  are  rarer.  The  last  mentioned  form  may  occur  as  free 
growths  in  the  ventricles.  Syphilitic  brain  diseases  or  gummata  are  of 
importance.  Tumors  of  the  meniuges  and  of  the  cranial  bones  are  also  seen. 

Symptoms. — The  symptoms  of  brain  tumor  fall  into  two  groups:  those 
due  to  increased  intracranial  pressure,  and  those  of  true  focal  character. 
In  a  large  number  of  tumors,  especially  those  situated  in  the  occipital  fossa 
or  the  cerebellum,  the  indications  of  a  congestive  hydrocephalus  appear.  In 
infancy,  indeed,  an  internal  hydrocephalus  may  dominate  the  entire  pic- 
ture (see  Fig.  119). 

Symptoms  of  intracranial  pressure,  precede,  as  a  rule,  the  appearance 
32 


498  TEXT-BOOK  OF  PEDIATRICS 

of  focal  symptoms  for  a  variable  period.  They  usually  include  intense 
headache,  cerebral  vomiting,  dizziness,  and  such  psychical  disturbances  as 
persistent  peevishness,  loss  of  interest  in  play,  mental  apathy,  and  constant 
drowsiness  which  finally  goes  on  to  distinct  sopor.  Even  in  these  early 
stages,  not  infrequently  mistaken  either  for  gastro-intestinal  disorders  or 
beginning  tuberculous  meningitis,  choked  disc  may  often  be  demonstrated. 
Its  discovery  is  of  the  first  importance  in  the  early  diagnosis  of  brain 
tumor.  It  is,  of  course,  often  absent,  and  particularly  in  tuberculous  tumors 
of  the  pons. 

General  convulsions  may  make  their  appearance  at  any  stage,  but  they 
are  frequently  lacking. 

The  focal  symptoms  are  of  two  groups:  first  the  phenomena  of  lost 
function  due  to  direct  injury  or  destruction  of  brain  tissue;  and,  second,  the 
more  remote  manifestations  resulting  from  pressure  of  the  tumor  upon 
neighboring  structures.  If  the  tumor  is  situated  in  the  so-called  silent  areas 
of  the  brain,  the  absence  of  function  does  not  cause  any  readily  recognized 
disturbance  and  all  the  focal  symptoms  may  be  lacking.  Paralysis  is  often 
preceded  by  evidences  of  irritation,  such  as  tremor,  twitching,  or  athetosis. 
Localized  clonic  contractions  are  among  the  important  focal  symptoms, 
and  may  even  terminate  in  general  epileptic  attacks,  or  Jacksonian  epilepsy. 

The  topographical  diagnosis  of  brain  tumor  cannot  be  undertaken  here; 
the  reader  is  referred  to  text -books  on  internal  medicine  and  neurology. 

Course. — Recovery  is  said  to  occur  in  those  forms  of  tumor  which  are 
due  to  syphilis  and  cysticerci  and,  uncommonly,  even  in  those  of  tubercu- 
lous origin.  In  cases  of  brain  tubercle,  death  usually  results  from  tubercu- 
lous meningitis  or  miliary  tuberculosis.  Sudden  death  may  occur  in  tumors 
of  the  posterior  fossa  as  a  direct  result  of  lumbar  puncture. 

Diagnosis. — Apart  from  the  consideration  of  the  topographical  diag- 
nosis, certain  essential  points  must  be  emphasized.  Tubercle  is  probable  if 
there  is  a  coexisting  tuberculosis  of  lymph  nodes  or  of  the  bones.  The. use 
of  the  von  Pirquet  test  is  important  for  its  exclusion.  In  children  tubercles 
are  always  multiple. 

The  question  of  syphilis  must  always  be  fully  considered  and  the 
Wassermann  reaction  should  be  made.  Roentgenography  may  be  em- 
ployed, especially  when  tumor  at  the  base  or  of  the  hypophysis  is  suspected. 
Lumbar  puncture  always  requires  extreme  care  in  the  suspected  presence 
of  brain  tumor,  but  it  may  be  necessary  for  the  exclusion  of  meningitis. 
Given  the  former,  the  pressure  of  the  cerebrospinal  fluid  is  increased,  but  it 
is  in  other  respects  normal.  Brain  tumor  is  often  only  to  be  differentiated 
from  some  forms  of  encephalitis  and  from  chronic  internal  hydrocephalus 
by  the  course  of  the  disease.  Acute  onset  and  a  history  of  pauses  or  retro- 
gressions are  evidence  against  brain  tumor.  The  diagnosis  of  brain  abscess 
must  be  considered  whenever  the  symptoms  point  to  the  cerebellum  or  to 
the  temporal  lobe  and  particularly  when  an  otitis  media  has  preceded  them 
within  a  certain  period  of  time. 

Treatment. — In  most  cases  treatment  must  be  symptomatic.  Antipyrin 
or  morphin  to  control  pain;  chloral  hydrate  for  protracted  convulsions; 


DISEASES  OF  THE  NERVOUS  SYSTEM  499 

lumbar  puncture,  if  necessary,  to  relieve  a  congestive  hydrocephalus  and 
its  resulting  symptoms.  The  latter  procedure  is  useful  only  when  the 
ventricles  are  not  occluded.  Operative  removal  of  the  tumor  is  a  possibil- 
ity only  in  exceptional  cases.  Generally  speaking,  only  the  cerebrum, 
the  cerebellar  portion  of  the  pons,  and  the  hypophysis  can  be  laid  open 
for  operation.  Surgical  interference  is  always  dangerous.  Simple  trephin- 
ing and  cerebral  puncture  to  relieve  pressure  is  a  palliative  measure  to 
be  considered. 

Large  doses  of  potassium  iodide  should  always  be  tried  even  though 
there  be  no  suspicion  of  syphilis.  It  has  often  had  a  favorable  influ- 
ence upon  other  forms  of  brain  tumor.  Of  course,  in  every  case  in 
which  lues  is  suspected  strenuous  antisyphilitic  treatment  must  be  instituted 
at  once. 

IX.  CEREBRAL  PARALYSIS  OF  CHILDREN:  INFANTILE 
CEREBRAL  PALSY 

SPASTIC  INFANTILE  HEMIPLEGIA  AND  DIPLEGIA 

The  term  cerebral  paralysis  of  children  covers  a  clinical  group.  It  is 
understood  to  represent  the  results  of  various  non-progressive  injuries 
which  affect  the  brain  in  earliest  childhood  or  before  birth.  In  the  study 
of  the  given  clinical  picture  the  localization  is  more  important  than  the 
nature  of  the  injury.  It  is  usually  impossible,  even  at  autopsy,  to  get 
definite  knowledge  of  the  nature  of  the  original  disease,  of  usual  occurrence 
many  years  before.  But  even  while  it  is  impossible  to  establish  definite 
criteria  of  general  application,  individual  clinical  types  may  be  very  easily 
selected  from  the  chaos  of  cases.  Indeed,  some  special  consideration  of 
hemiplegic  and  diplegic  forms  is  quite  opportune,  because  etiologically  they 
have  a  distinct  viewpoint  from  which  their  prognosis  may  be  determined. 
Nevertheless,  it  must  not  be  forgotten  that  a  continuing  series  of  transi- 
tional cases  relates  the  individual  types. 

Etiology. — A  number  of  predisposing  factors  enter  into  the  origin  of  the 
cerebral  paralyses  of  childhood.  These  are  often  operative  even  when  the 
direct  cause  of  the  disease  is  known,  the  development  of  which  depends  upon 
a  certain  lack  of  resistance  of  the  brain  tissue  to  injury.  Thus  the  disease 
occurs  in  children  who  are  members  of  a  family  in  which  a  succession  of 
nervous  and  mental  disorders  has  been  observed.  It  is  often  possible  to 
show  that  the  parents  were  tuberculous  or  luetic  or  that  the  father  was  an 
alcoholic.  Either  the  first-born  or  the  youngest  of  a  family  is  affected  with 
relative  frequency. 

The  direct  cause  is  either  of  a  traumatic  or  infective  nature.  Birth 
traumata  are  responsible  for  many  cases,  particularly  of  the  diplegic  type. 
Severe  and  protracted,  or  violent  and  rapid  labor,  inducing  a  serious  degree 
of  asphyxia  in  the  child,  is  believed  to  play  some  causative  part,  but  prob- 
ably a  less  frequent  one  than  is  commonly  supposed.  Meningeal  hemor- 
rhages resulting,  as  a  rule,  from  a  tearing  of  the  veins  at  their  entry  into 


500  TEXT-BOOK  OF  PEDIATRICS 

the  sinuses,  are  doubtless  an  actual,  but  not  as  exclusive  cause  of  injury 
to  the  brain. 

Premature  birth  is  another  important  etiologic  factor.  Many  children 
who  suffer  with  spastic  paraplegia  were  prematurely  born.  Nevertheless,  it 
is  to  be  remembered  that  prematurity  and  difficult  labor  are  not  infre- 
quently recorded  in  the  history  of  cases  in  which  the  origin  of  the  disease 
doubtless  dates  back  a  long  time  before  birth.  Such  instances  afford  an 
opportunity  for  error  in  determining  the  actual  causes  of  the  condition. 
It  is  quite  possible  that  some  of  these  prenatal  cases  may  have  arisen  in 
part  from  traumata  received  during  pregnancy  and  perhaps  even  from 
psychic  traumata.  A  certain  percentage  of  them,  whether  of  prenatal 
or  postnatal  development,  may  be  traced  to  syphilitic  or  so-called  para- 
syphilitic  disease. 

Brain  embolism  or  encephalitis  may  occur  in  the  course  of  infectious 
disease.  This  is  particularly  true  of  pertussis,  diphtheria,  scarlet  fever, 
measles,  influenza,  and  occasionally  of  almost  any  infectious  disease. 
Certain  of  these  cases  present  a  definite  brain  disease  in  themselves — the 
acute  polioencephalitis  of  Striimpell,  a  form  already  discussed  under  the  head 
of  acute  encephalitis. 

In  general  the  rule  of  the  so-called  Little's  etiology  may  be  accepted, 
viz.,  that  difficult  labor,  premature  birth,  and  asphyxia  of  the  new-born  cause 
most  of  the  diplegic  cerebral  paralyses,  while  the  majority  of  the  hemiplegic 
paralyses  appear  only  after  birth  and  are  of  infective  origin. 

Pathologic  Anatomy. — In  the  greater  number  of  cases  the  initial  lesion 
is  of  vascular  type,  in  the  way  of  hemorrhage,  embolism  or  thrombosis.  In 
a  minor  number  it  is  due  to  some  inflammatory  process.  Pure  degenerative 
changes  in  the  cerebral  cortex  are  probably  very  rare.  It  has  been  said 
already  that  cases  are  seen,  as  a  rule,  only  in  their  later  stages  when  any 
conclusion  as  to  the  nature  of  the  original  lesion  is  no  longer  possible.  The 
brain  by  that  time  shows  more  or  less  localized  destruction,  foci  of  softening, 
scars,  cysts,  and  particularly  structural  defects  of  the  cortex,  by  way  of 
excavated  funnel-shaped  depressions  which  may  extend  into  the  ventricles, 
the  so-called  porencephaly  (Heschl).  Sometimes  the  finely  graven  convo- 
lutions of  the  cortex  described  as  microgyria  are  seen.  Instead  of  these 
localized  foci,  a  more  diffuse  injury  is  often  observed  in  the  form  of  a 
sclerosis,  or  hardening,  and  contraction  of  large  areas  or  entire  divisions  of 
the  brain  (atrophia  cerebri).  The  tuberous  scleroses  present  a  peculiar 
type,  hi  which  single,  hard,  nodular  areas  are  scattered  throughout  the 
brain.  Cases  in  which  no  gross  lesions  of  the  central  nervous  system  are 
discoverable  macroscopically,  but  in  which  microscopic  examination  reveals 
a  diffuse  proliferation  of  the  neuroglia  and  a  destruction  of  nerve  cells,  are 
not  uncommon.  The  meninges  often  show  the  results  of  old  inflammatory 
processes,  in  the  way  of  cloudiness,  adhesions  and  thickening,  the  results 
of  which,  like  those  of  many  cases  of  recovered  meningitis  or  hydro- 
cephalus,  cannot  be  distinguished  clinically  from  true  cerebral  paralyses. 
Frequently  pathologic  conditions  are  found  in  the  pyramidal  tracts. 


DISEASES  OF  THE  NERVOUS  SYSTEM  501 

SPASTIC  INFANTILE  HEMIPLEGIA;  UNILATERAL  CEREBRAL 
PARALYSIS  OF  CHILDREN 

Hemiplegias  are  distinguished  in  a  general  way  from  diplegias  by  the 
facts  that  they  are  usually  of  postnatal  origin,  that  the  arm  is  more  com- 
monly and  more  severely  affected  than  the  leg,  that  they  result  more  fre- 
quently in  disturbances  of  growth,  and  oftener  lead  on  to  epilepsy. 

Typical  cases  take  something  of  an  acute  course,  after  the  manner 
described  in  encephalitis.  The  hemiplegia  often  coincidently  affects  the 
face.  The  paralysis  is  at  first  flaccid,  but  soon  takes  on  a  spastic  type. 
The  actual  paralysis  of  motion  is  often  less  prominent  than  are  the  muscular 
spasms.  Aphasia,  commonly  present  in  the  beginning,  soon  disappears,  and 
in  time  the  paralysis  itself  partially  clears  up,  especially  in  the  leg,  while  in 
the  arm  contractures  are  apt  to  follow.  As  the  paralysis  improves,  choreic 
and  athetotic  movements  often  develop  on  the  paralyzed  side  of  the  body. 
The  growth  of  the  affected  parts  is  retarded.  The  mental  faculties  are  at 
times  slightly,  or  may  be  severely  affected.  After  weeks,  months,  or  even 
years,  typical  epilepsy,  often  of  progressively  increasing  gravity,  may  appear. 

Special  Symptoms. — The  distribution  of  the  paralysis  may  be  very 
regular.  The  palsy  of  the  facial  nerve,  in  its  later  stages,  may  be  discernible 
only  by  careful  observation,  as  when  the  patient  begins  to  smile  or  to  cry. 
Of  other  cranial  nerves,  the  hypoglossal  is  not  infrequently  affected,  while 
strabismus  or  involvement  of  the  motor  oculi  is  very  uncommon.  Pupillary 
fixation  may  be  significant  of  a  luetic  cause. 

As  to  the  extremities,  the  arm  and  especially  the  hand  is,  as  a  rule,  more 
severely  affected  than  the  leg.  There  are  many  cases  in  which  the  leg 
recovers  so  largely  as  to  give  the  casual  observer  the  impression  that  only  a 
monoplegic  paralysis  of  the  arm  has  occurred.  Only  by  careful  examination, 
by  noting  the  increase  of  the  patellar  reflex,  and  by  the  discovery  of  slight 
differences  in  growth,  as  between  the  well  and  the  affected  sides,  is  it 
possible  to  arrive  at  a  correct  conclusion.  The  exaggeration  of  the  deep 
reflexes  is  the  most  constant  and  persistent  symptom.  Of  course,  the 
patellar  reflex  may  often  be  exaggerated  upon  the  normal  side,  but  the 
unilateral  difference  will  be  distinct  nevertheless.  Babinski's  sign,  the 
stretching  of  the  great  toe  when  the  sole  of  the  foot  is  scratched,  is  fre- 
quently found  on  the  affected  side.  Coincidently  with  the  increase  of  the 
reflexes,  the  pathognomonic  rigidity  characteristic  of  the  disease  develops. 
This  is  usually  most  masked  in  individual  groups  of  muscles  and  particu- 
larly in  the  flexors  and  pronators  of  the  arms  and  in  the  flexors  of  the  legs. 
Resulting  contractures  soon  appear.  The  leg  is  slightly  flexed  and  rotated 
inward;  the  foot  is  drawn  downward  and  inward;  the  arm  is  flexed  to  a 
right  angle;  the  forearm  is  drawn  up  and  pronated,  and  the  hand  may  be 
fixed  in  varied  positions.  In  cases  of  relatively  long  standing  the  contrac- 
ture  cannot  be  overcome  even  when  considerable  force  is  employed.  To 
these  continuing  contractions,  sometimes  scarcely  noticeable,  are  added 
spasms  occurring  upon  voluntary  motion.  These  are  usually  very  distinct 
and  serve  as  a  serious  embarrassment  to  the  use  of  the  limbs.  The  patient 


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constantly  struggles  against  intrinsic  obstacles  and  his  movements  become 
exaggerated  and  slow.  From  the  functional  point  of  view  these  spasms  are 
often  much  more  annoying  than  the  paralysis.  Indeed,  true  paralysis  may 
be  found  upon  careful  examination  to  be  entirely  absent.  The  intensity  of 
the  one  is  quite  independent  of  that  of  the  other.  The  paralysis  may  be 
most  marked  in  the  hand;  the  rigidity  may  bo  most  definite  in  the  leg  or 
in  the  musculature  of  the  shoulder.  Ataxia  and  intention  tremor  are  not 
infrequently  coincident  with  the  paresis. 

On  account  of  the  spastic  fixation  of  the  lower  extremity  the  gait  is  often 

very  characteristic.  The  foot  is  not  car- 
ried directly  forward,  but  is  advanced  by 
a  circular  swing  operating  from  the  hip; 
it  drags  a  little  and  the  toes  only  are 
planted  on  the  ground.  In  milder  cases, 
the  awkwardness  of  action  may  appear 
only  when  the  child  attempts  to  stand  on 
one  foot  or  tried  to  hop  or  to  stand  on 
his  toes. 

In  walking,  a  peculiar  movement,  quite 
typical  of  cerebral  paralysis  in  children,  is 
observed.  The  faster  the  child  walks  the 
higher  is  the  affected  arm  raised,  wing- 
fashion,  and  waved  to  and  fro  in  the  air 
(see  Fig.  127).  These  associated  move- 
ments may  be  imitative  of  those  on  the 
normal  side  in  every  detail,  as  is  very 
strikingly  shown  if  the  child  is  allowed  to 
roll  a  bread  pill  between  its  fingers.  The 
involuntary  movements  of  the  affected 
limbs  are  very  noticeable  and  very  annoy- 
ing. They  appear  in  the  later  stages  of 
the  disease  in  about  one-third  of  the  cases 
the  onset  of  which  occurs  in  advanced 
childhood.  The  quick,  jerking  movements, 
usually  affecting  an  entire  extremity,  or 
the  shoulder  girdle,  or  the  facial  muscles, 
constitute  chorea;  while  the  slower,  rhythmic,  flexing,  or  extending,  stretch- 
ing motions  of  the  fingers  and,  at  times,  of  the  toes,  are  termed  athetosis. 
Frequently,  grimaces  are  of  similar  quality. 

Chorea  and  athetosis  are  in  a  degree  antitheses  of  the  paralyses.  The 
more  completely  the  paralysis  and  the  spasms  disappear,  the  more  varied 
do  the  involuntary  movements  become.  In  extreme  cases,  they  make 
the  limbs  almost  impossible  of  control.  As  an  intermediate  phase  between 
the  spasmic  and  athetosic  conditions  one  often  sees  an  athetoid  spreading 
of  the  fingers,  with  an  excessive  degree  of  passive  mobility  which  tends 
to  their  over-extension. 

The  paretic  limbs  commonly  suffer  from  trophic  changes.    These  usually 


FIG.  127. — Right  sided  spastic  infantile 
hemiplegia.  Spastic  paresis  of  right  arm 
and  leg  with  atrophy  of  musculature. 
Delayed  growth  of  right  side  of  body. 
Fixed  talipes  equinus.  Wing-like  elevation 
of  right  arm  in  walking. 


DISEASES  OF  THE  NERVOUS  SYSTEM  503 

take  the  form  of  a  delayed  growth  or  hypotrophy  of  the  affected  parts,  in 
the  matter  both  of  length  and  mass,  which  may  involve  a  high  grade  of 
atrophy  in  their  musculature. 

Epilepsy  and  idiocy,  as  complications  of  the  disease,  are  of  grave 
significance  in  considering  the  ultimate  fate  of  the  patient.  More  than  half 
of  these  sufferers  become  epileptics.  The  convulsions  which  accompanj'- 
the  initial  stage  of  the  disease  are  usually  followed  by  an  interval  of  weeks, 
months,  or  even  years,  during  which  the  patient  remains  free  from  attack. 
Subsequently  epileptic  seizures  set  in,  increase  in  frequency  and  may  con- 
tinue throughout  life.  Even  the  mildest  cases,  in  which  recovery  from  the 
paralysis  is  almost  complete,  are  not  secure  from  this  serious  complication. 

Disturbances  of  the  intelligence,  like  epilepsy,  are  the  sad  sequelae  of 
many  cases  of  infantile  hemiplegia.  In  very  few  cases  do  the  mental 
faculties  remain  wholly  unimpaired  and  even  in  these  exceptions  a  dis- 
tinct change  in  character  is  often  observed.  The  patient  grows  irritable 
and  shows  a  tendency  to  fits  of  temper  and  acts  of  violence.  All  degrees 
of  mental  degeneration,  from  slight  imbecility  to  most  complete  idiocy, 
are  recorded. 

Choreic  Paresis. — This  term  is  used,  according  to  Freud  and  Rie,  to  des- 
ignate those  clinical  forms  in  which  the  hemichorea  has  not  been  preceded 
by  the  stage  of  spastic  paralysis.  As  a  rule,  it  is  of  insidious  development 
in  older  children  who  do  not  suffer  from  epilepsy,  from  marked  disorders 
of  intelligence,  or  errors  of  growth. 

SPASTIC  INFANTILE  DIPLEGIA;  CEREBRAL  DIPLEGIA 
OF  CHILDREN 

The  most  serious  forms  of  cerebral  diplegia  are  grouped,  in  the  liter- 
ature of  these  cases,  under  the  name  of  Little's  disease  and,  according  to 
Freud,  are  termed  general  spastic  disease  whenever  the  entire  body  is 
involved,  or  paraplegic  spastic  disease  when  the  lower  limbs  alone  are 
affected.  These  forms  are  distinguished  by  the  fact  that  spasticity  of  the 
limbs  is  the  dominant  feature  of  the  disease-picture  and  that  the  legs  are 
the  more  seriously  paralyzed  or  are  alone  affected.  They  are  further  char- 
acterized by  a  distinctly  regressive  tendency,  and  by  the  evidence  of  their 
prenatal  origin  or  of  an  etiology  in  birth  traumata  in  the  great  majority 
of  cases.  In  instances  of  general  spasticity  it  is  very  often  possible  to  obtain 
a  history  of  asphyxia  neonatorum  and  of  difficult  labor;  while  premature 
birth  is  more  frequently  relational  to  paraplegic  spasticity  (Feer,  Freud). 

Severe  cases  of  general  spasticity  appear  even  in  early  infancy.  The 
child  seems  to  be  as  stiff  and  rigid  as  a  stick  of  wood  and  is  difficult  to  dress 
or  to  change.  It  is  impossible  to  make  him  sit  up.  Such  an  one,  however, 
marks  an  extreme  grade  of  the  disease,  usually  provoked  by  intra-uterine 
injury.  Milder  forms  are  discovered  by  the  parent  or  even  by  the  physician 
only  when  the  child  is  old  enough  to  begin  to  learn  to  walk,  when  it  is 
found  that  the  spasticity  of  the  legs -makes  this  impossible  or  extremely 
difficult.  Many  a  patient  so  afflicted  never  learns  to  walk  or  does  so  only  in 
later  years.  Placed  upon  the  feet  they  present  a  very  characteristic  picture. 


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The  thighs  are  rotated  inward  and  the  knees  are  pressed  firmly  together  in 
consequence  of  spasm  of  the  adductors.  The  tips  of  the  toes  only  touch  the 
floor.  If  the  attempt  to  walk  is  made,  the  knees  are  pushed  past  each 
other  with  great  exertion,  the  legs  tend  to  cross  (Fig.  130),  and  the  child 
advances  only  by  rotating  upon  the  axis  of  its  body.  When  the  spasms  are 
less  severe,  and  they  sometimes  improve  slightly  with  increasing  years,  the 
patient  may  be  able  to  walk,  but  only  by  constantly  overcoming  the  nerv- 
ous tension.  The  slow  and  strained  gait  gives  one  the  impression  of  a 
person  wading  in  deep  mud.  The  toe  step  remains  throughout.  Upon 

lying  down  or  rising  up,  the  legs 
are  often  moved  completely  in 
unison,  as  though  they  are  bound 
together.  In  sitting  they  are  held 
horizontally,  on  account  of  the 
extensor  spasms. 

The  spasticity  is  usually  less 
marked  in  the  arms  and  often 
does  not  involve  the  trunk  at  all. 
Chorea,  involuntary  movements, 
and  typical  athetoses  are  much 
less  common  in  the  diplegias  than 
in  the  hemiplegias,  but  an  athetoid 
spreading  of  the  fingers  and  toes 
is  often  met  with.  Tremor  and 
ataxia  are  not  at  all  rare.  The 
deep  reflexes,  especially  in  the 
lower  extremities,  are  always  exag- 
gerated, but  the  degree  of  spas- 
ticity may  hide  the  patellar  reflexes 
entirely.  At  rest,  the  spasms  are 
often  less  marked,  but  reappear 
upon  voluntary  action  or  brisk 
passive  motion.  As  a  rule,  they 
are  especially  marked  when  the 
attempt  is  made  to  stand  the  child 
upon  its  feet. 

In  the  paraplegic  forms,  the  nerves  supplying  the  ocular  muscles  are 
frequently  involved,  producing  a  degree  of  strabismus.  Optic  atrophy, 
inequality  of  the  pupils  and  nystagmus,  are  not  of  exceptional  occurrence. 
If  the  facial  nerves  are  affected  the  spasticity  gives  to  the  face  a  mask-like 
expression,  which  is  in  sharp  contrast  to  the  forced  mimicry  it  displays-  upon 
the  exercise  of  emotion,  as  when  the  child  cries  or  is  frightened.  Dysarthria 
and  bradylalia  are  often  noted  and,  combined  with  the  difficult  operation  of 
the  muscles  of  expression,  give  one  the  suggestion,  at  times,  of  a  high  degree 
of  imbecility,  even  though  the  intelligence  may  not  be  very  seriously 
affected.  Spasm  of  the  pharyngeal  muscles  may  occasion  difficulty  in 
swallowing.  Retardation  of  growth  and  actual  hypoplasia  of  the  limbs 


Fio.  128. — Cerebral  diplegia  (Little's  disease). 
Premature  birth  at  seven  months.  Asphyxia.  Cross- 
ing of  legs  on  attempting  to  walk,  strabismus,  dys- 
arthria,  easily  frightened. 


DISEASES  OF  THE  NERVOUS  SYSTEM 


505 


take  a  less  important  place  in  this  form  of  paralysis  than  in  the  hemi- 

plegic  type.    The  musculature  may  show  some  atrophy,  but  occasionally  is 

hypertrophic.     The  constant  finding 

of  the  high  position  of  the  patella 

(Schulthess),  which  becomes  a  most 

prominent  symptom  when  the  knee  is 

sharply  flexed,  is  significant. 

Attacks  of  spasms  or  convulsions 
are  quite  frequent  shortly  after  birth 
in  all  forms  of-  diplegia.  Later  con- 
vulsions, of  the  epileptic  type,  are 
decidedly  less  frequent  than  in  hemi- 
plegic  paralysis.  Indeed,  in  paraplegic 
spasticity  they  are  of  quite  uncom- 
mon occurrence. 

In  the  cerebral  diplegias,  failures 
of  intelligence  and  even  idiocy  of  seri- 
ous degree,  are  common  and  naturally 
so,  since  a  certain  percentage  of  cases 
result  from  grave  malformations  of 
the  brain.  A  small  head,  the  so-called 
pseudo-microcephaly,  may  be  notice- 
able even  at  birth.  Nevertheless, 
there  are  cases,  especially  of  the  para- 
plegic type,  in  which  the  mental  facul- 
ties are  partially  or  well  developed. 

It  has  been  noted  already  that 
Little 's  disease  shows  a  tendency  to 
improvement.  After  a  number  of 
years  only  the  stiffness  of  the  legs  may 
remain  of  the  general  spastic  disorder. 
Paraplegic  spasticity  may  disappear 
completely  in  the  course  of  time. 

PECULIAR  TYPES  OF  THE  DISEASE 

Those  forms  of  the  disease  in  which  the  manifestations  of  spasticity  are 
distinctly  confined  to  the  lower  extremities  are  called  paraplegic  paralyses. 

Pronounced  cases,  associated  with  a  high  degree  of  idiocy  and  with  well 
developed  epilepsy,  and  in  which  the  arms  are  more  or  less  seriously  affected, 
even  to  the  point  of  contractures,  indicate  a  doubling  of  the  hemiplegic 
conditions  and  are  designated  as  bilateral  spastic  hemiplegia. 

Pseudobulbar  paralysis  (Oppenheim,  Peritz),  is  a  term  applied  to  cases 
of  the  latter  type  to  which  is  added  a  bilateral  involvement  of  the  cranial 
nerves.  The  title  suggests  a  symptom-complex  which  results  from  bi- 
lateral disturbances  in  the  brain  areas  controlling  the  muscles  of  expression, 
deglutition  and  speech,  and  resembles  very  closely  the  disease-pictures 


FIG    129. — Four-year-old    boy.      Microcephaly. 
General  muscular  rigidity,  atheosis,  idiocy. 


506  TEXT-BOOK  OF  PEDIATRICS 

produced  by  injuries  to  the  gray  nuclei  of  the  cranial  nerves  in  the  medulla. 
Pseudobulbar  paralysis  may  also  be  seen  in  the  congenital  form  of  general 
spastic  disease.  Facial  expression  is  wholly  wanting  in  these  bilateral 
spastic  types:  the  face  appears  vacant  as  though  carved  in  stone.  The 
control  of  facial  movement  may  be  so  lacking  that  in  place  of  a  smile  the 
face  is  distorted  into  the  risus  sardonicus.  In  the  more  markedly  paretic 
forms  the  patient  cannot  pucker  the  lips,  distend  the  cheeks,  or  protrude 
the  tongue.  The  control  of  suckling  and  swallowing  is  usually  less  dis- 
turbed and  the  movements  of  the  facial  muscles  in  laughing  or  crying  may 
be  well  regulated.  At  times,  the  child  will  use  the  fingers  to  push  the  food 
into  the  grasp  of  the  more  automatic  muscles  of  the  pharynx  by  which  the 
normal  act  of  deglutition  is  performed  involuntarily. 

General  Chorea  and  Bilateral  Athetosis. — These  terms  relate  to  those 
severe  forms  of  disease  in  which  local  voluntary  choreic  movements,  or 
simultaneous,  generalized,  associated  movements  dominate  the  clinical 
picture.  Constantly  recurring,  jerky  motions  of  the  entire  body  and  often 
repeated  grimacing  are  observed.  The  functions  of  speech  and  of  voluntary 
movement  are  seriously  impaired,  particularly  in  the  more  severe  pareses. 
Frequently  an  abnormal  flaccidity  of  the  muscles  replaces  the  hypertonia. 

Cerebellar  Forms. — There  are  forms  of  the  disease  in  which  impairment 
of  cerebellar  coordination  is  a  prominent  feature.  The  disability  is  seen 
both  in  standing  and  sitting  and  in  an  abnormal  flaccidity  of  the  muscles 
in  general. 

An  atonic-astatic  type  of  infantile  cerebral  paralysis  resembles,  in  a 
degree,  the  cerebellar  forms.  This  disease-picture,  so  well  outlined  by  O. 
Foerster,  is  featured  by  a  generalized  atony,  by  the  absence  of  all  involun- 
tary resistance  to  passive  motion  in  the  muscles,  which  results  in  a  marked 
overextension  of  the  joints,  and  by  a  loss  of  control  of  static  function.  Each 
individual  muscle  may  be  made  to  contract  by  stimulation  of  its  nerve 
supply,  but  the  patient  is  unable  to  stand  or  to  sit.  He  simply  collapses. 
The  head  cannot  be  held  erect  but  falls  to  one  side.  As  in  all  the  cerebral 
diplegias  of  children,  the  disease  shows  a  distinct  tendency  to  improvement 
continuing  over  a  period  of  many  years.  It  would  seem  that  this  type, 
which  in  its  primary  stages  occasionally  appears  in  the  common  forms  of 
general  spasticity,  is  dependent  upon  lesions  in  the  frontal  lobes.  According 
to  Clark,  who  has  proposed  the  name  of  cerebro-cerebellar  diplegia,  it  is  a 
condition  in  which  the  functions  of  the  cerebral  and  cerebellar  hemispheres 
are  coincidently  affected. 

Infantile  Spastic  Spinal  Paralysis  or  Spasmatic  Tabes. — This  term  was 
formerly  employed  to  designate  the  pure  spastic  pareses  of  the  legs  or  of 
all  the  extremities  which  were  believed  to  be  localized  in  the  cord.  Their 
cerebral  origin  is  now  clear  in  those  forms  which  exhibit  strabismus, 
mental  disturbances,  speech  disorders,  and  epilepsy.  To-day  there  is  a 
general  tendency  to  consider  them  all  as  of  cerebral  localization.  Since, 
however,  these  diseases  frequently  affect  the  new-born,  it  is  generally  be- 
lieved that  they  may  lead  to  a  delay  in  the  development  of  the  cortico- 
spinal  bundles  and,  particularly,  of  the  pyramidal  tracts.  A  spasticity 


DISEASES  OF  THE  NERVOUS  SYSTEM 


507 


without  paralysis,  the  more  severe  involvement  of  the  legs,  and  a  gradual 
spontaneous  improvement  during  life  may  find  a  very  satisfactory  explana- 
tion in  this  manner. 

Familial  forms  of  cerebral  diplegia  and  of  amaurotic  idiocy  belong  to  the 
hereditary  degenerative  diseases  and  are  discussed  under  that  head. 

Diagnosis. — The  several  clinical  forms  are  not  always  sharply  distin- 
guished and  mixed  forms  are  often  seen.  The  pathologic  conditions  in  the 
brain  cannot  be  determined  during  life.  According  to  Vogt,  the  coincident 
development  of  sebaceous  adenomata 
of  the  skin  is  characteristic  of  a  tu- 
berous sclerosis  of  the  brain.  High 
degrees  of  microcephaly  are  indicative 
of  a  prenatal  origin. 

During  infancy  it  is  often  impos- 
sible to  recognize  the  milder  cases, 
since  hypertonia  is  physiologic  and  is 
emphasized  in  many  of  the  chronic 
disturbances  of  nutrition.  A  marked 
exaggeration  of  the  reflexes  and  espe- 
cially the  evidence  of  idiocy  may 
establish  diagnosis,  while  abnormally 
early  closure  of  the  fontanelle  may 
afford  the  first  suspicion. 

In  fully  developed  cases,  the  dif- 
ferentiation of  the  disease  from  forms 
of  paralyses  of  peripheral  origin  (poli- 
omyelitis, birth  palsies,  etc.),  which 
may  present  a  similar  picture,  partic- 
ularly when  they  have  led  to  well- 
marked  contractures,  is  of  the  greatest 
importance.  The  spastic  character  of 
the  paralysis,  the  increase  of  the 
reflexes,  the  less  pronounced  atrophy, 
the  mental  defects,  the  development 
of  epilepsy,  or  of  choreic  and  athetoid 
movements,  all  testify  to  cerebral 
paralysis.  When  doubt  prevails,  an  electrical  examination  gives  definite 
distinctions.  In  the  cerebral  paralyses,  the  affected  muscles  give  normal 
reactions  to  the  galvanic  and  faradic  currents.  By  this  means,  also,  the 
atonic-astatic  forms  may  probably  be  distinguished  from  congenital  mus- 
cular atony  which  affects  the  muscles  of  the  trunk  and  neck  less  severely 
and  shows  a  reduced  irritability  to  electrical  tests. 

In  every  case  the  question  of  brain  syphilis  must  be  given  careful  con- 
sideration. Doubtful  subjects  demand  the  Wassermann  reaction.  In- 
equality of  the  pupils,  and  especially  their  failure  to  react  to  light,  must  be 
considered  as  strong  indications  of  syphilis. 

Brain  tumor,  in  many  instances,  may  be  distinguished  from  the  disease 


FIG  130. — Cerebral  diplegia  (Little's  disease) , 
so-called  tabes  spasmodique.  Tetra  spasm,  in- 
distinct in  the  arms.  Intelligence  good.  Pre- 
mature birth  at  seven  months. 


508  TEXT-BOOK  OF  PEDIATRICS 

under  discussion  only  by  its  progressive  course  or  by  the  presence  of  choked 
disc.  This  is  measurably  true  of  hydrocephalus  in  older  children  which 
may  simulate  spastic  diplegia. 

If  nystagmus,  intention  tremor,  and  bradylalia  occur  under  para- 
spastic  conditions  the  picture  may  resemble  that  of  multiple  sclerosis  very 
closely.  But,  on  the  one  hand,  it  is  quite  certain  that  the  latter  disease 
hardly  ever  occurs  in  childhood  and,  on  the  other  hand,  that  atypical  cases 
of  cerebral  diplegia  frequently  belong  to  the  familial  forms  which  are  usu- 
ally characterized  by  a  progressive  course.  The  disease  is  differentiated 
from  Friedreich's  ataxia  by  the  symptoms  of  spasticity  and  by  the  exag- 
gerated reflexes. 

Amaurotic  idiocy  and  diffuse  sclerosis  can  be  mistaken  for  cerebral 
diplegia  only  if  the  progressive  nature  of  the  disease  is  ignored. 

Prognosis. — Many  hemiplegias  and  most  cases  of  general  and  paraplegic 
tetany  have  a  tendency  to  spontaneous  recovery.  Children  affected  learn 
to  walk  at  the  age  of  eight  or  ten  years.  The  prognosis  is  governed  chiefly 
by  the  state  of  the  intellect  and  by  the  absence  or  presence  of  epilepsy. 
The  appearance  of  the  latter  can  never  be  foretold  in  hemiplegia  even  of 
mild  form. 

Treatment. — The  treatment  of  meningeal  hemorrhages  of  the  new-born 
and  of  acute  encephalitis  has  been  already  discussed.  When  syphilis 
is  an  etiologic  factor  an  energetic  antisyphilitic  treatment  is  indicated. 
For  the  rest  the  aim  of  treatment  must  be  to  develop  the  best  degree  of 
motor  function. 

For  this  purpose  electricity  may  be  used.  The  paretic  muscles  are 
stimulated  with  the  induced  current  and  the  anode  of  the  galvanic  current  is 
passed  over  the  spastically  contracted  ones.  Protracted  warm  baths  also 
aid  in  relaxing  the  hypertonicity  and  may  be  given  frequently,  for  weeks  at 
a  time,  especially  in  the  diplegias. 

Properly  conducted  and  long  continued  active  exercises  are  of  the 
greatest  importance.  Their  practice  requires  a  certain  measure  of  intelli- 
gence and  good-will  on  the  part  of  the  patient.  Advantage  may  be  taken  of 
the  tendency  of  the  affected  member  to  move  in  unison  with  the  well  limb, 
so  that  it  is  well  to  permit  the  latter  to  participate  in  the  training  (H. 
Curshmann).  Exercise,  supported  by  massage  and  passive  motions,  is 
possible  and  useful  only  after  the  contractures  have  been  relieved  by  tenot- 
omy  and  readjustment.  Thus  the  treatment  of  these  cases  has  been  rightly 
relegated  more  and  more  to  the  domain  of  orthopedics  which  has  an  oppor- 
tunity for  great  results. 

In  hemiplegia  the  deformities  of  the  foot  are  readily  corrected  by  the 
plastic  lengthening  of  the  tendo  Achillis.  In  the  arm,  a  lessening  of  the 
hypertonus  and  a  strengthening  of  the  paretic  muscle  groups  can  be 
achieved  by  proper  tendon  transplantation,  transferring  parts  of  the  hyper- 
tonic  muscles  into  functionally  inactive  muscles.  The  observation  that 
chorea  and  athetosis  do  not  occur  in  a  member  upon  which  tendon  oper- 
ations have  been  performed  is  especially  interesting.  This  is  an  all  the  more 


DISEASES  OF  THE  NERVOUS  SYSTEM  509 

important  fact  because  these  function-disturbing  involuntary  movements 
are  but  little  influenced  by  other  methods  of  treatment. 

In  diplegia  very  beautiful  results  have  been  obtained  by  putting  the  legs 
in  plaster  and  keeping  them  in  the  Gratsch  position  for  a  considerable 
period  after  the  bilateral  tenotomy  of  the  tensor  fascia  lata  in  the  popliteal 
space,  of  the  adductors  and  the  flexors,  and  of  the  tendo  Achillis  (Fig.  131). 
Careful  after-treatment  with  massage  and  with  active  and  passive  exercise 
enables  the  patient  to  walk  within  a  few  months.  The  crooked  back  is 
usually  a  very  difficult  problem  in  correction.  As  already  noted,  treatment 
is  effectual  only  if  the  intelligence  is  fairly  well  preserved. 

Very  recently,  good  results  have  been  obtained  in  several  cases  of  Little 's 
disease  by  Foerster's  operation.  The  principle  of  this  operation  lies  in 
relieving  excessive  irritability  of  sensory  nerves  leading  to  the  spastic 
muscle  groups,  which  serves  to  excite  the  spasms.  To  accomplish  this 


Fio.  131. — Cerebral  diplegia  (Little's  disease).  Mask-like  facies.  Legs  held  in  the  Gratsch 
position  by  plaster  dressing  after  preceding  tenotomy  of  the  tendon  Achillis,  the  flexors  of  the  leg, 
the  adductors  and  of  the  the  tensor  fascia  lata. 

several  of  the  posterior  nerve  roots  arc  laid  bare  in  the  spinal  canal  and  are 
cut.  This  operation  may  prove  to  have  a  great  future.  The  selection  of 
the  roots  to  be  cut  is,  of  course,  a  very  important  matter.  It  will  suffice  to 
call  attention  to  Foerster's  original  reports. 

Stoffels'  operation  follows  a  different  therapeutic  principle.  It  is  di- 
rected to  the  weakening  of  the  spastic  muscle  groups  by  the  section  of  a 
part  of  the  motor  nerve  supply  in  the  peripheral  nerve  trunks.  Thus  in 
hemiplegic  paralyses  of  the  arm  the  functional  relations  may  be  materially 
improved  by  the  weakening  of  the  pronators  and  flexors,  by  a  resection  of 
the  median  nerve  in  the  bicipital  groove.  Similarly,  the  spastic  toe  step 
is  corrected  by  resection  of  a  part  of  the  tibial  nerve. 

Both  the  Foerster  and  the  Stoffel  operations  demand  careful  orthopedic 
after-treatment,  with  massage  and  with  active  and  passive  exercise,  in 
order  to  insure  permanent  results. 

The  treatment  of  epilepsy  in  this  disease  is  identical  with  that  of  its 
true  forms.  In  a  few  cases  trephining  and  the  excision  of  the  primary 


510  TEXT-BOOK  OF  PEDIATRICS 

disease  focus  in  the  cortex,  or  the  removal  of  offending  cysts  or  scar- 
tissue  has  proved  useful.  Disturbances  of  speech  and  intelligence  require 
pedagogic  treatment.  Clearly  idiotic  patients  should  be  placed  in  suit- 
able institutions. 

X.  SCLEROSIS  OF  THE  CENTRAL  NERVOUS  SYSTEM 

Partial  secondary  scleroses  of  entire  divisions  of  the  brain  and  tuberous 
sclerosis  have  been  discussed  in  an  earlier  chapter  (page  500). 

Diffuse  sclerosis  of  the  brain  is  a  rare  disease.  It  may  be  a  sequel  of 
traumata  and  usually  begins  insidiously  during  the  first  year  of  life.  In  the 
course  of  months,  or  even  years,  it  eventually  terminates  fatally.  It  is 
occasionally  interrupted  by  epileptiform  or  apoplectic  attacks  which  are 
associated  with  aggravations  of  the  primary  disease. 

Its  symptoms  consist  in  a  progressive  spastic  paralysis  of  the  entire 
musculature,  together  with  a  loss  of  speech  and  intelligence  going  on  to 
complete  unconsciousness.  The  optic  nerves  become  atrophic.  The  hard- 
ening of  the  brain  and  spinal  cord,  and  especially  of  the  white  matter,  is  de- 
pendent chiefly  upon  a  prolif  eration  of  the  neuroglia  and  is  to  be  looked  upon 
as  the  result  of  an  interstitial  inflammation. 

Multiple  focal  sclerosis  is  extremely  uncommon  in  childhood,  probably 
occurring  only  as  the  terminal  stage  of  multiple  encephalomyelitis.  It  is 
usually  sequent  to  acute  febrile  diseases.  It  is  hardly  necessary  to  discuss 
the  malady  further  since  its  course  and  symptomatology  are  identical  with 
those  witnessed  in  the  adult.  Briefly,  the  symptoms  include  spastic  par- 
esis of  the  legs,  intention  tremor,  optic  atrophy,  nystagmus,  sensory  dis- 
turbances, bradylalia,  paralysis  of  the  sphincters,  etc.  The  majority  of 
the  children  who  present  a  corresponding  symptom-complex  are  suffering 
with  some  atypical  form  of  cerebral  diplegia  or  with  some  type  of  heredi- 
tary degenerative  disease,  as  familial  diplegia,  hereditary  ataxia,  etc.  Multi- 
ple sclerosis  may  be  simulated  by  progressive  paralysis,  brain  syphilis, 
and  hysteria. 

XI.  ACUTE   POLIOMYELITIS;  SPINAL  PARALYSIS 
OF  CHILDREN 

(HEINE-MEDIN'S  DISEASE;  ACUTE  EPIDEMIC  INFANTILE  PARALYSIS) 
Acute  infantile  paralysis  is  an  infectious  disease  of  the  central  nervous 
system,  occurring  in  widespread  epidemics  or  in  sporadic  form,  and  most 
common  in  early  childhood.  The  term  acute  anterior  poliomyelitis  applies 
to  the  type  of  greatest  clinical  importance.  The  name  signifies  the  local- 
ization of  the  disease  processes  in  the  anterior  cornua  of  the  spinal  cord.  It 
causes  flaccid  paralyses,  affecting  individual  muscle  groups,  which  may 
persist  throughout  life. 

Etiology  and  Epidemiology. — The  greatest  epidemics  of  recent  years  in 
the  Scandinavian  countries,  in  North  America,  Germany  and  Austria  have 
greatly  enlarged  our  knowledge  of  the  disease. 

Cases  of  seemingly  sporadic  occurrence  must  be  looked  upon  as  the  re- 
siduum of  lingering  epidemics  which  doubtless  present  more  such  single 


DISEASES  OF  THE  NERVOUS  SYSTEM  511 

cases  than  we  ordinarily  suspect.  This  is  the  more  true  because,  up  to  the 
present  time,  abortive  cases  in  which  no  paralysis  develops  are  diagnosed 
only  during  epidemics  and  even  then  with  relative  infrequence. 

Children  in  the  first  three  years  of  life  are  by  far  the  most  definitely 
prediposed  to  the  disease,  although  adults  are  also  attacked.  In  the  epi- 
demics recorded,  the  largest  number  of  cases  have  occurred  during  the  sum- 
mer months,  particularly  in  July  and  August,  but  continuing  to  October. 

Landsteiner  and  Popper  have  succeeded  in  inoculating  monkeys  with 
the  disease.  From  the  recent  researches  of  Flexner,  Roemer  and  others, 
in  experimental  poliomyelitis  in  monkeys,  we  have  learned  that  the  incuba- 
tion period  is  from  eight  to  nine  days,  that  the  virus  passes  through  the 
Berkfeld  filter,  and  has  the  consistency  of  glycerin.  Further,  it  reaches  the 
central  nervous  system  by  way  of  the  lymph  passages  and,  outside  of  the 
nervous  system,  it  may  also  be  found  in  the  nasal  and  pharyngeal  mucus  and 
in  the  saliva.  Apparently  it  is  not  affected  by  the  gastric  juice  and  has 
been  found  in  the  feces.  This  virus  is  destroyed  quickly  by  high  tempera- 
tures, but  resists  cold  and  drying.  One  attack  confers  immunity.  Immune 
bodies  which,  being  mixed  with  the  virulent  infectious  material,  destroy  its 
virulence,  are  found  in  the  blood  alike  of  human  being  and  monkey,  con- 
valescent from  the  disease. 

The  method  of  spread  is  probably  by  contagion  from  person  to  person, 
in  which  event,  as  in  epidemic  meningitis,  healthy  or  but  mildly  affected 
carriers  play  the  most  active  part  (Wickman).  In  convalescents,  the  virus 
is  evidently  present  in  a  virulent  form  for  many  weeks  in  the  secretion's  of 
the  mucous  membranes  and  in  the  membranes  themselves  (Kling,  Peterson 
and  Wernstedt).  It  has  been  found  also  in  the  dust  of  the  sick-room.  It 
has  been  proved  beyond  contradiction  that  stinging  flies  (Stomoxys  Calci- 
trans),  may  transmit  the  disease.  No  other  insects  and  neither  food 
material  nor  drinking  water  enter  into  its  etiologic  consideration. 

The  causative  organism  has  recently  been  obtained  in  pure  culture 
by  Flexner  and  Noguchi.  It  is  an  extremely  small  globular  cell  which  in 
view  of  its  cultural  characteristics  must  be  classed,  in  all  probability,  as 
a  bacterium. 

The  port  of  entry  of  the  organism  seems  to  be  both  in  the  digestive  and 
the  respiratory  tracts,  but  particularly  in  the  pharyngeal  ring.  Numer- 
ous cases  have  been  found  among  the  children  of  families  in  which  the  sever- 
ity of  the  disease  has  varied  widely,  abortive  forms  being  seen  in  some  of 
the  members. 

Pathologic  Anatomy. — In  children  dying  in  the  acute  stages  of  the 
disease,  focal  hemorrhagic  changes  in  the  anterior  horns,  and  most  com- 
monly in  the  cervical  and  lumbar  enlargements,  may  be  seen  macroscopi- 
cally.  Microscopic  examination  shows  that  the  inflammatory  process, 
which  apparently  spreads  in  the  vascular  sheaths  (Wickman),  may  not 
only  extend  to  the  posterior  horns,  but  even  to  the  white  matter,  and  is 
always  more  diffuse  than  would  be  imagined  from  the  clinical  findings. 
The  meninges  always  show  inflammatory  changes  under  the  microscope 
(Warbitz  and  Schell).  As  a  consequence  of  the  inflammatory  process  in  the 


512  TEXT-BOOK  OF  PEDIATRICS 

region  of  the  gray  matter,  extensive  injuries  of  the  ganglion  cells  and  often 
neuronophagia  are  found. 

In  older  cases  the  disease  foci  are  sclerotic  and  atrophic.  The  ganglion 
cells  have  disappeared  or  degenerated;  the  vessel  walls  are  thickened,  the 
glia  proliferated,  and  the  entire  half  of  the  cord  may  appear  contracted  even 
to  the  naked  eye.  The  anterior  horn  is  narrowed  and  the  boundary  between 
the  posterior  horn  and  the  white  matter  is  blurred.  The  affected  muscles 
are  more  or  less  degenerated  and  are  salmon-colored,  bright  pink,  gray,  or 
even  yellowish  in  tint  and  at  times  broadly  striated. 

Symptoms  and  Course. — The  incubation  period  varies  from  five  to  ten 
days,  and  occasionally  may  be  shorter.  It  is  followed  by  a  febrile  initial 
stage,  which  gradually  passes  into  the  period  of  beginning  paralysis.  The 
latter,  in  turn,  goes  on  to  permanent  paralyses  and  contractures. 

The  initial  stage  is  characterized  by  pyrexia,  frequently  exceeding  39°- 
40°  C.  (102°-104°  R).  There  is  marked  disturbance  of  the  general  health. 
The  pulse  is  usually  very  rapid;  the  sensorium  is  affected  slightly  if  at  all; 
there  is  a  great  desire  for  sleep  which,  however,  is  restless  and  disturbed  by 
dreams  and  delirium.  Locally,  it  may  be  possible  in  some  cases  to  find  an 
angina  present;  in  others  there  may  be  bronchitis,  and,  again,  such  digestive 
disturbances  as  stomatitis,  vomiting  and  diarrhrea,  or  a  severe  degree  of 
obstipation.  There  is  but  little  headache  and  typical  general  epileptiform 
convulsions  are  rare.  Herpes  may  be  present,  but  is  extremely  uncommon. 
The  temperature  usually  falls  to  normal  after  the  first  few  days,  but  occa- 
sionally runs  a  typical  course  for  a  week  or  two.  This  early  stage,  which 
presents  great  difficulties  of  diagnosis,  is  further  marked  by  several  signif- 
icant symptoms.  The  most  important  of  these,  and  the  one  which  first 
invites  the  parents'  attention,  is  an  extreme  sensitiveness  of  the  skin  to 
touch,  and  the  expression  of  pain  on  passive  motion.  The  child  screams  as 
soon  a?  an  attempt  is  made  to  lift  him,  or,  indeed,  when  the  mother  or  the 
physician  even  approaches  the  bed.  He  refuses  to  be  moved  from  the  bed 
and  begs  to  be  left  alone.  If  he  is  raised  he  stiffens  the  spine,  which  does 
not  otherwise  indicate  hypertonia.  He  makes  frequent  complaints  of 
spontaneous  pains  in  the  back  and  in  the  muscles ;  and  an  extreme  sensitive- 
ness to  pressure  over  the  nerve  roots  may  be  shown  for  a  long  time  after  the 
early  stage  has  passed.  A  second  important  symptom  is  the  great  tendency 
to  perspiration.  To  these  must  be  added  a  third  finding,  established  by  E. 
Miiller,  a  distinct  leucopenia  (3,000-5,000  leucocytes).  Not  one  of  these 
symptoms  is  constant,  and  even  leucocytoses  have  been  reported  several 
times.  At  this  period,  lumbar  puncture  usually  reveals  a  cerebrospinal 
fluid  under  increased  pressure  and  commonly  clear,  although  it  is,  now  and 
then,  opalescent.  Its  protein  content  is  increased  and  a  fibrin  clot  may  de- 
velop upon  standing.  Sediment  obtained  from  it  by  centrifuging  shows  a 
lymphocytosis.  Cultures  from  it  are  negative,  and  after  the  recrudescence 
of  the  initial  stage  these  pathologic  findings  disappear. 

This  stage  rarely  lasts  longer  than  two  or  three  days.  Doubtless  there 
are  cases  in  which  it  passes  in  several  hours  arid  is  entirely  unnoticed,  so 
that  the  patient  who  went  to  bed  seemingly  well  wakes  up  paralyzed  in  the 


DISEASES  OF  THE  NERVOUS  SYSTEM 


513 


morning.  The  early  paralyses  are  usually  distributed  over  the  greater  part 
of  the  body.  Paralysis  may  be  preceded  by  spasms  and  jerking  of  the  af- 
fected parts.  It  is  of  a  flaccid  type,  involving,  most  frequently,  the  legs  and 
trunk  and,  less  often,  the  arms  and  the  areas  supplied  by  the  cranial  nerves. 

It  reaches  its  maximum  spread  in  from  a  few  hours  to  a  few  days  and 
after  this  period  of  initial  development  it  shows  only  retrogressions.  Suc- 
cessive attacks,  affecting  new  parts,  are  very  exceptional. 

The  paralysis  is  not  always  easily  recognized  at  first ;  but  upon  careful 
examination  a  hypotonicity,  or  at  least 
an  absence  of  patellar  reflexes  is  always 
discovered.  Very  often  the  muscles  of 
the  trunk  and  abdomen  are  first  affected 
and  then  the  seemingly  meteoric  disten- 
sion of  the  abdomen,  contrasting  with 
the  flaccidity  of  the  abdominal  wall, 
attracts  attention.  Then,  too,  the 
patient  cannot  sit  up  or  maintain  a  sit- 
ting posture.  Disturbances  of  control 
of  the  urinary  and  anal  sphincters  are 
common  in  the  initial  stage,  but  are 
always  transient.  Retention  of  urine, 
requiring  catheterization,  occurs  only 
when  the  lumbar  segments  of  the  cord 
are  involved,  and  it  is  then  coincident 
with  paraplegia  of  the  legs. 

The  muscular  paralysis  is  often  re- 
lieved, to  a  considerable  extent  in  the 
course  of  succeeding  days  or  weeks. 
Entire  members,  completely  paralyzed, 
may  fully  recover  the  power  of  motion. 
A  considerable  number  of  cases,  indeed, 
are  restored  without  any  apparent  de- 
fects, but  these  are,  of  course,  the 
exceptions.  Some  part  of  the  muscle 
groups  originally  paralyzed  usually  suf- 
fers permanent  injury. 

The  paralyses  are  flaccid;  they  are 
peripheral  and  produce  atrophy.  If  the  affected  limbs  are  raised  they  fall 
back  inanimately  upon  the  bed.  The  deep  reflexes  are  lost.  The  electri- 
cal examination  reveals  reactions  of  degeneration  which  are  soon  followed 
by  atrophy  of  the  muscles.  While  the  nerves  and  muscles  are  often  exces- 
sively irritable  at  first,  both  to  mechanical  and  electrical  stimulation,  they 
soon  fail  to  respond  to  excitation  with  the  induced  current  and  only 
respond  to  the  direct  current  by  slow  wave-like  contractions  in  which  the 
anodal  phase  is  the  greater. 

Muscles  in  which  the  reactions  of  degeneration  are  fully  established 
33 


FIG.  132. — Acute  anterior  poliomyelitis. 
Paralytic  club-foot  on  right  due  to  paralysis  of 
the  extensors  of  the  toes  and  of  the  muscles  of 
the  calves.  The  tibialis  anticus  and  the  flexors 
of  the  toes  are  normal.  Atrophy  of  the  thigh 
and  leg. 


514 


TEXT-BOOK  OF  PEDIATRICS 


recover  incompletely  or  not  at  all.  In  the  course  of  epidemics,  however, 
exceptions  to  this  rule  have  been  observed. 

The  disappearance  of  the  deep  reflexes  and  especially  of  the  patellar 
reflex,  again,  is  the  rule;  but  in  the  event  of  paralyses  of  the  arms  alone, 
exaggerated  patellar  reflexes  have  been  observed  several  time?.  This  is 
readily  explained  in  view  of  the  coincident  affection  of  the  white  matter 
of  the  cord  which  may  lead  to  an  injury  of  the  pyramidal  tracts.  The  tendo 
Achillis  reflex,  or  ankle  clonus,  often  proves  to  be  exaggerated.  The  skin 

reflexes  may  be  intact  or  may  be 
wanting,  when  the  underlying  mus- 
cles are  affected.  The  Babinski 
phenomenon  may  be  positive. 

The  atrophy  of  the  muscles 
often  causes  marked  loss  of  size 
and  form  in  the  limbs.  The  natural 
modelling  is  lost  and  the  entire 
member  may  seem  to  consist  merely 
of  skin  and  bone.  In  very  young 
children  the  loss  of  muscle  mass  is 
sometimes  masked  by  the  develop- 
ment of  fatty  tissue. 

The  various  types  of  paralysis 
may  present  many  combinations 
but,  in  actual  experience,  they  take 
certain  prevailing  forms.  Most  fre- 
quently only  one  leg  remains  par- 
alyzed ;  more  rarely  a  single  arm  or 
both  legs;  occasionally  paraplegia 
of  the  arms,  crossed  hemiplegias, 
and  even  hemiplegic  varieties  are 
seen.  It  is  characteristic  of  acute 
poliomyelitis  that  the  paralysis 
never  affects  all  the  muscles  of  the 

FIG.  133.— Paralysis  of  the  abdominal  muscles  and       entire     limb     equally.       Individual 

tiieraptsaiylectingbothleg8followingepidemicinfan"    muscle  groups  are  involved,  while 

others   remain   free.     Very  often 

muscles  which  are  associated  functionally,  even  when  supplied  by  entirely 
distinct  nerves,  are  simultaneously  affected.  In  the  leg  the  peronei  are  most 
commonly  paralyzed.  The  participation  of  the  quadriceps  and  the  tibialis 
anticus  in  the  paralysis,  while  the  sartorius  remains  free,  is  a  frequent  pic- 
ture. In  the  arm  the  deltoid  is  most  frequently  affected,  while  the  smaller 
muscles  of  the  hand  generally  escape.  The  muscles  of  the  neck  and  trunk 
very  often  suffer  at  the  outset,  but  they  usually  recover.  If  this  is  not  the 
case,  serious  scolioses  and  lordoses  ensue.  Paralyses  of  the  abdominal 
muscles  may  leave  localized  atrophied  areas  in  the  abdominal  wall  which 
result  in  hernia  upon  deep  respiration  or  muscular  strain  (Fig.  133). 

Paralyses  of  the  bulbaror  pontine  forms,  involving  the  cranial  nerves, 


DISEASES  OF  THE  NERVOUS  SYSTEM 


515 


very  rarely  observed  among  sporadic  cases,  occur  quite  frequently  in  the 
course  of  epidemics.  The  facial  nerve  is  the  most  frequently  affected,  while 
the  abducens,  the  hypoglossal,  and  the  oculomotor  are  seldom  attacked. 
If  the  nucleus  of  the  vagus  is  invaded,  dyspnoea  results  and  in  most  cases 
causes  death. 

These  paralyses  show  the  most  rapid  improvement  during  the  first 
week,  although  gradual  improvement  may  take  place  during  the  ensuing 
half-year  and  even  later.  The  possibilities  of  improvement  should  be 
limited  perhaps  to  one  year  from  the  invasion  of  the  disease.  After  the 
disappearance  of  the  initial  symptoms,  the  general  condition  is  usually 
excellent.  A  certain  psychical  irritability  and  peevishness,  and  a  tendency 


FIG.  134. — Acute  poliomyelitis.     Paralysis  of  the  musculature  of  the 
trunk  and  legs. 

to  pain  in  the  limbs  may  be  noticeable  for  a  time.  The  absence  of  sensory 
disturbances  is  especially  characteristic  of  the  later  stages  of  the  disease  and 
has  a  diagnostic  value. 

The  stage  of  permanent  paralysis  is  further  distinguished  by  secondary 
results  in  the  way  of  contractures  and  deformities  which  cripple  the  unfor- 
tunate child  for  life.  If  all  or  nearly  all  the  muscles  of  an  extremity  are 
paralyzed,  contractures  are  not  formed,  but  the  limb  hangs  limply  from 
the  body  like  that  of  a  doll. 

If,  however,  only  individual  muscle  groups  are  affected,  a  more  usual 
result,  the  action  of  antagonistic  muscles  causes,  within  a  few  weeks,  the 
development  of  contractures,  which  by  the  shortening  of  tendons  and  the 
fibrous  degeneration  of  the  muscular  tissue  itself,  acquire  a  fixed  abnormal 
position.  The  pressure  even  of  the  bed-clothes  and  of  the  body,  when  rest- 
ing upon  the  limb,  increase  the  tendency  to  the  development  of  such  deform- 


516  TEXT-BOOK  OF  PEDIATRICS 

ities.  These  contractures  are  harmful,  in  themselves,  in  that  they  cause  an 
overstrain  and  thus  do  further  injury  to  partially  paralyzed,  weakened, 
but  not  always  entirely  useless  muscles.  Serious  functional  disorder  is  also 
involved  in  the  formation  of  flail-joints,  which  are  especially  to  be  dreaded 
in  the  shoulder  and  hip. 

Disturbances  of  growth  are  not  uncommon.  There  is  always  the  ques- 
tion of  shortening  of  an  affected  limb.  The  skin  of  the  paralyzed  extrem- 
ities often  appears  pale  or  cyanotic  and  markedly  colder  to  the  touch  than 
that  on  the  well  side.  The  severe  lordoses  and  scolioses  which  may  result 
from  paralysis  of  the  muscles  of  the  trunk  have  been  previously  mentioned. 
Paralytic  contractures  of  the  leg  and  foot  are  very  common  and  very 
troublesome.  According  to  the  nature  of  the  paralysis,  talipes  planus, 
equinus,  or  cavus  results.  An  extreme  degree  of  contraction  may  make  the 
patient  walk  on  the  dorsum  of  the  foot.  Genu  incurvatum  and  recurvatura 

are  also  sequent  to  poliomyelitic 
paralyses  and  are  not  infre- 
quently seen. 

With  the  loss  of  the  quad- 
riceps alone,  or  in  combination 
with  severe  paralyses  of  the 
muscles  of  the  back,  the  child 
is  often  able  to  move  about  only 
on  all  fours  or  to  drag  himself 
along  by  his  hands. 

Forms  pursuing  a  peculiar 
course  have  been  brought  into 
recognition  by  the  brilliant 
studies  of  Wickman,  who  is  to 
be  credited  with  gathering 

FIG.  135. — Acute  poliomyelitis,  hand  walker.  ,  ,  .  ..    .      , 

together  the    various    clinical 
varieties  under  the  name  of  Heine-Medin 's  disease. 

1.  Abortive  forms  are  apparently  very  common  in  the  course  of  epi- 
demics and  doubtless  escape  diagnosis  when  they  appear  sporadically. 
Typical  initial  symptoms,  of  even  intense  degree,  appear,  with  which  dis- 
turbances of  digestion,  anginas,  or  meningeal  manifestations  may  be  asso- 
ciated.   The  marked  depression,  the  pain  in  the  limbs,  and  the  fever  often 
give  the  impression  of  an  influenza.     A  correct  diagnosis  is  made  only  upon 
the  appearance  of  paralyses  in  other  members  of  the  family  who  are  simi- 
larly affected.    In  cases  of  this  abortive  type  recovery  is  rapid  and  complete, 
even  when  the  diminution  of  the  patellar  reflex  and  the  hypotonicity  of 
various  muscle  groups  leave  no  doubt  that  the  disease  is  acute  poliomyelitis. 
The  survivors  of  these  abortive  forms  are,  moreover,  immune. 

2.  Cases  with  fatal  course.    Death  is  caused  far  less  frequently  by  the 
severity  of  the  infection  than  by  the  localization  of  the  process  in  the  vital 
centres  in  the  medulla.     These  centres,  as  a  general  thing,  are  not  pri- 
marily affected.    The  disease  process  may  be  initially  developed,  for  in- 
stance, in  the  nuclei  of  the  cranial  nerves  situated  in  the  pons  and  the 


DISEASES  OF  THE  NERVOUS  SYSTEM  517 

interbrain,  whence  it  causes  paralyses  of  the  ocular  and  facial  muscles. 
Descending,  it  reaches  the  region  of  the  vagus  and  the  respiratory- 
centres.  Yet  more  frequently,  the  path  taken  in  these  fatal  cases  resembles 
that  of  the  ascending  spinal,  or  Landry's  paralysis.  The  disease  passes 
from  the  centres  governing  the  leg  muscles  to  those  of  the  trunk,  thence  to 
those  of  the  arms  and,  finally,  to  the  respiratory  centres,  in  rapid  succession. 
This  form  of  the  disease  usually  terminates  fatally  within  a  very  few  days  and 
rarely  lasts  as  long  as  two  weeks.  It  is  preferentially  occurrent  among  older 
children.  The  fever  is  not  especially  high  and  the  temperature  may  even 
reach  a  normal  point  during  the  closing  days.  A  fatal  outcome  is  not 
invariable.  The  disease  process  may  be  arrested  even  after  the  respiratory 
centres  are  affected. 

3.  Pontine  and  bulbar  forms  have  been  already  described.    Paralyses  of 
the  ocular  and  facial  muscles,  of  the  soft  palate,  and  of  the  tongue  occur 
not  only  as  initial  symptoms,  associated  with  widely  distributed  paralyses 
of  the  extremities,  but  in  occasionally  isolated  types,  and  produce  clinical 
pictures  which  simulate  superior  or  inferior  polioencephalitis.    When  such 
acute  peripheral  paralyses  as,  for  instance,  in  the  distribution  of  the  facial 
nerve,  appear  sporadically,  it  is  always  permissible  to  entertain  the  sus- 
picion of  acute  poliomyelitis. 

4.  Encephalitic  or  cerebral  forms,  leading  to  spastic  hemiplegia,  or  to 
cerebral  infantile  palsy  are  known,  but  are  of  quite  rare  occurrence  in  the 
course  of  epidemics  (see  Chapter  on  Encephalitis,  page  491),  Wickman  fur- 
ther describes  yet  more  rare  clinical  types  as  atactic  meningitis  and  poly- 
neuritic  forms. 

Diagnosis. — The  diagnosis  is  difficult  in  the  initial  stages,  but  may  often 
be  made  successfully  if  proper  weight  is  given  to  the  characteristic  sensi- 
tiveness to  touch,  to  the  pain  upon  motion,  accompanied  by  an  unclouded 
sensorium  which  distinguishes  it  from  epidemic  meningitis,  to  the  profuse 
perspiration,  and  to  the  leucopenia.  When  there  is  danger  of  its  confusion 
with  meningitis,  a  lumbar  puncture,  and  the  demonstration  of  disturbed 
electrical  reactions  in  the  various  muscle  groups  should  decide  the  question. 
At  the  onset,  some  cases  are  mistaken  for  muscular  or  articular  rheumatism, 
influenza,  sciatica,  polyneuritis  or  tuberculous  meningitis.  The  rapid 
development  of  poliomyelitic  paralyses,  reaching  their  maximum  spread 
within  a  few  days,  the  flaccid,  atrophic  quality  of  these  paralyses,  the 
absence  of  sensory  disturbances,  and  of  interference  with  urinary  or  rectal 
control  after  the  subsidence  of  the  acute  symptoms  are  characteristic  and  of 
distinct  diagnostic  value. 

Differential  Diagnosis. — Multiple  neuritis  is  very  uncommon  in  young 
children.  It  goes  on  to  complete  paralysis  very  gradually- and  is  marked  by 
long  continued  fever.  Sensory  disturbances  persist  even  in  its  late  stages. 
The  implication  of  cranial  nerves  and  the  fact  of  pain  upon  pressure  over 
the  nerves  and  muscles  involved  can  hardly  be  utilized  in  this  differentiation. 
Ataxia  is  rather  indicative  of  polyneuritis,  but  it  may  also  occur  in  polio- 
myelitis. When  the  muscles  affected  are  strictly  limited  to  the  peripheral 
innervation,  the  condition  is  very  probably  polyneuritis.  Bilateral  sym- 


518  TEXT-BOOK  OF  PEDIATRICS 

metrical  symptoms,  associated  with  the  early  appearance  of  edema,  are 
similarly  indicative  of  neuritis.  The  polyneuritic  form  of  infantile  paral- 
ysis is  apt  to  be  recognized  only  in  epidemic  invasions. 

Post-diphtheritic  paralyses  also  develop  gradually.  Furthermore,  in 
this  condition  sensory  and  ataxic  disturbances  affect  the  soft  palate  in  partic- 
ular, which  poliomyelitis,  on  the  contrary,  is  only  exceptionally  involved. 

Cerebral  paralysis  of  children  may  now  and  then  occasion  difficulty  in  its 
differentiation  from  the  more  circumscribed  processes.  The  contractures  of 
poliomyelitis,  for  instance,  may  simulate  spasms.  The  reactions  of  degen- 
eration, as  well  as  the  diminution  or  loss  of  the  deep  reflexes,  are  indicative 
of  infantile  paralysis.  It  must  not  be  forgotten,  however,  that  exaggeration 
of  the  patellar  reflex  and  of  the  ankle  clonus  may  occur  in  poliomyelitis, 
and  especially,  in  those  forms  in  which  the  arms  are  paralyzed.  There  can 
be  no  doubt  of  cerebral  paralysis  when  athetosis,  chorea,  idiocy,  or  epi- 
lepsy develop. 

Birth  paralyses  of  one  or  both  arms,  when  they  are  first  observed  in 
childhood,  cannot  be  distinguished  from  poliomyelitic  paralyses  saving  by 
aid  of  the  history.  Inward  rotation  of  the  arm,  as  a  result  of  paralysis  of 
the  infraspinatus,  is  common  in  birth  palsies.  Myatonia  congenita  may  be 
recognized  by  the  widespread,  symmetrical  flaccidity  of  the  musculature 
and  by  the  absence  of  the  reactions  of  degeneration. 

Progressive  muscular  dystrophy  is  a  disease  the  differentiation  of  which, 
in  difficult  cases,  can  only  be  made  from  the  history  and  by  careful  observa- 
tion of  its  course.  The  dystrophies  are  bilaterally  symmetrical  and  are 
gradually  progressive.  Paralysis  of  the  legs  in  spina  bifida  occulta  is  often 
combined  with  paralyses  of  the  sphincters  and  with  usually  symmetrical 
sensory  disturbances. 

Pseudoparalyses,  due  to  delayed  growth  in  rickitic  patients,  or  in  con- 
genital lues,  may  be  mistaken  for  the  paralyses  of  poliomyelitis.  Careful 
observation,  however,  shows  their  pseudonymic  quality.  They  do  not 
involve  changes  in  electrical  reactions. 

Paralysie  douloureuse,  so-called,  produced  by  jerking  the  arm  in  small 
children  is  also  recognized  as  a  pseudoparalysis  and  recovers  promptly 
when  proper  treatment  is  applied. 

Hysterical  monoplegias,  uncommon  in  childhood,  may  occur  with  dis- 
tinct atrophy,  but  give  normal  electrical  reactions. 

Paralysis  of  the  abdominal  muscles,  due  to  poliomyelitis,  have  been 
repeatedly  mistaken  for  true  abdominal  hernia.  The  demonstration  of 
coincident  results  of  infantile  paralysis  and  the  location  of  the  protruding 
tumor  should  protect  one  from  this  error. 

Prognosis. — 'The  older  the  patient,  the  greater  the  danger  of  a  fatal 
termination.  No  prognostic  conclusions  can  be  drawn  from  the  height  of 
the  fever.  In  epidemics  the  mortality  from  the  disease  varies  between  ten 
and  twenty  per  cent. 

Complete  recovery  is  not  very  common.  The  severity  of  the  epidemic 
must  be  considered  in  answering  all  questions  of  prognosis.  Even  widely 
distributed  paralyses  may  disappear,  but  the  resultant  functional  disturb- 


519 

ances  are  usually  less  severe  if  only  a  small  area  has  been  involved  in  the 
paralysis  at  the  outset.  The  electrical  reactions  will  assist  the  prognosis  of 
individual  muscle  groups,  since  those  that  remain  responsive  to  the  induced 
current  and  do  not  give  degenerative  reactions  will  undoubtedly  recover, 
while  those  with  complete  reactions  of  degeneration  permit  but  a  poor 
outlook  for  their  full  restoration.  The  reappearance  of  spontaneous  volun- 
tary movements  in  paralytic  areas  is  particularly  important.  The  return 
of  function  often  precedes  the  reestablishment  of  normal  electrical  reactions 
by  a  long  period.  Of  the  permanent  paralyses,  those  seriously  affecting  the 
trunk  muscles,  as  well  as  paraplegias  of  the  legs,  particularly  when  they 
involve  the  quadriceps  and  the  muscles  of  the  hip,  compel  a  very  grave 
prognosis.  If  but  one  leg  is  paralyzed,  it  is  usually  possible,  by  the  pursuit 
of  modern  orthopedic  methods,  to  enable  the  patient  to  walk. 

Treatment. — -During  the  first  few  days,  absolute  rest  and  quiet  are 
essential.  Very  few  but  very  fortunate  experiences  have  been  reported 
with  the  plaster  of  Paris  bed  designed  for  the  entire  body  by  the  orthopedists. 
A  bland  diet,  the  absolute  avoidance  of  alcoholic  and  even  minor  stimulants, 
and  the  effective  care  of  the  bowels  are  demanded.  Frequently  acetyl- 
salicylic  acid  or  sodium  salicylate  are  given,  and  by  rectum  if  necessary, 
during  the  initial  stage.  Hexamethylenamine  may  be  tried.  If  graver  symp- 
toms appear,  and  particularly  the  indications  of  ascending  paralysis,  blood- 
letting over  the  spine,  at  the  supposed  level  of  the  lesion,  or  a  therapeutic 
lumbar  puncture,  should  be  employed. 

Even  in  mild  cases  rest  in  bed  must  be  strictly  enforced  for  two  or  three 
weeks.  After  the  initial  stage,  physical  treatment  of  the  muscles  should  be 
undertaken  and  should  be  continued  uninterruptedly  so  long  as  there  is  any 
remaining  hope  of  thereby  improving  function.  This  treatment,  consisting 
of  massage  and  electricity,  should  be  continued  for  months.  It  makes 
great  demands  upon  the  endurance  of  physician  and  patient  alike,  but  it  is 
quite  certain  that  improvement  and  often  recovery  of  the  muscles  are 
achieved  much  more  rapidly  and  completely  under  such  treatment  than 
is  had  if  the  paralyzed  limbs  are  let  alone. 

Properly  directed  massage  takes  the  most  important  place  among  phy- 
sical methods  of  treatment.  It  should  be  employed  once  or  twice  a  day  for 
short  sessions  and  in  widely  distributed  paralyses  and  in  bed-ridden  cases 
it  should  extend  to  the  exercise  of  the  normal  but  inactive  musculature  also. 
The  development  of  permanent  contractures  must  be  counteracted  by 
active  and  passive  movements.  In  fact,  this  tendency  should  be  pre- 
guarded  by  the  position  which  the  child  occupies  in  the  bed.  He  should  not 
be  permitted  to  lie  with  the  legs  drawn  up  or  curled  up  in  a  ball.  In  paral- 
yses of  the  legs  the  feet  must  be  protected  from  the  pressure  of  the  bed- 
clothes by  suitable  wire  frames.  In  some  cases  it  will  be  found  necessary 
to  apply  proper  splints  very  early  in  the  course  of  the  disease  in  order  to 
prevent  contractures  and  overextension  of  the  weakened  muscles. 

With  the  massage,  warm  baths  35°-38°  C.  (95°-100°  F.)  have  been  use- 
fully combined.  The  addition  to  the  bath  of  aromatics  or  of  salt  may 
be  made. 


520  TEXT-BOOK  OF  PEDIATRICS 

The  curative  value  of  electricity  is  not  so  well  established.  The  strength 
and  quality  of  the  currents  employed  must  be  so  regulated,  with  reference 
to  each  stage  of  the  paralysis,  as  to  barely  excite  contractions.  Usually, 
therefore,  the  anode  is  passed  slowly  over  the  affected  muscle,  while  the 
strength  of  the  current  is  carefully  graded.  The  induced  current  is  useful 
only  in  slightly  impaired  or  convalescing  muscles.  Care  must  be  taken  to 
avoid  injurious  effects  of  the  electricity.  In  very  young  children  an 
indirect  injury  may  be  very  easily  done  by  the  undue  moistening  and  cooling 
of  large  areas  of  the  body-surface  in  the  application  of  wet  electrodes. 

Electric  treatment  should  be  given  daily,  at  first,  in  five  or  ten  minute 
sittings;  and  later  every  other  day.  After  a  period  of  treatment  covering 
four  to  eight  weeks,  it  is  well  to  discontinue  it  for  a  week  or  two.  Medici- 
nally, strychnia  or  the  iodides  may  be  added. 

A  little  later  it  becomes  very  important,  particularly  in  extensive  paral- 
yses, to  improve  the  general  condition,  so  far  as  possible,  by  a  nutritive 
dietary  and  by  the  opportunity  of  country  or  mountain  air. 

If  the  paralyzed  limb  but  partially  recovers,  the  normal  muscles  must 
be  safeguarded  from  the  evils  of  inactivity  by  exercise  and  resisted 
movements. 

Permanent  deformities  very  often  show  wonderful  improvement  under 
orthopedic  treatment.  Even  children  who  are  reduced  to  moving  about  on 
all  fours,  may  be  enabled  to  stand  by  protracted  corrective  measures. 
Operative  interference  is  indicated  only  when  spontaneous  repair  has 
ceased  which,  in  general,  will  be  from  nine  months  to  a  year  from  the  onset 
of  the  disease.  Premature  operative  attempts  are  apt  to  fail. 

The  proper  selection  of  available  measures  for  relief  must  be  made,  in 
each  individual  case,  in  the  light  of  a  careful  study  of  the  functions  which 
have  been  lost,  of  those  which  are  absolutely  requisite,  and  of  those,  again, 
which  may  most  readily  be  dispensed  with — an  exercise  of  art,  in  the 
true  sense  of  the  word,  which  demands  complete  knowledge  and  control  of 
the  technic. 

Ambulatory  splints  are  never  curative,  but  of  merely  palliative  effect. 
For  the  purpose  of  fixing  flail-joints,  of  regulating  the  movements  of  par- 
tially paralyzed  muscles,  and  of  correcting  abnormal  joint  positions,  they 
may  be  indispensable.  In  arthrodesis  of  the  shoulder,  knee,  or  ankle  joint, 
when  all  or  a  majority  of  the  muscles  controlling  the  joint  have  been  de- 
stroyed, artificial  ankylosis  may  be  necessary.  Thus,  for  instance,  a 
paralyzed  arm  which  hangs  helpless,  but  in  which  the  musculature  of  the 
forearm  and  hand  are  preserved,  may  regain  a  large  measure  of  its  normal 
usefulness  if  it  is  ankylosed  in  its  proper  position  at  the  shoulder. 

A  third  procedure  is  the  method  of  tendon  transplantation  after 
Niccoladoni.  Healthy  muscles,  or  portions  of  them  are  used  for  the  repro- 
duction of  lost  function  by  uniting  them  with  the  peripheral  tendons  of 
paralyzed  muscles  or  by  transferring  their  muscular  power  through  artificial 
silk  tendons  (Linge),  to  the  required  point  of  insertion  on  the  bone.  These 
admirable  methods  have  been  greatly  elaborated  and  have  proved  extremely 


DISEASES  OF  THE  NERVOUS  SYSTEM  521 

useful  in  many  cases.  For  further  particulars  the  reader  is  referred  to 
the  orthopedic  text-books  and,  particularly,  to  the  exhaustive  monographs 
of  Vulpius. 

XII.  DISEASES  OF  THE  SPINAL  CORD 
1.  MYELITIS 

The  most  important  member  of  this  group,  acute  poliomyelitis,  has 
been  discussed  under  the  synonym  of  Heine-Medin 's  disease  or  acute 
infantile  paralysis.  All  other  forms  of  myelitis,  and  transverse  myelitis  in 
particular,  are  comparatively  rare  in  childhood.  As  in  adult  life,  they 
exhibit  symptoms  of  pain,  sensory  disturbance  and  paraplegia,  the  func- 
tions of  bladder  and  rectum  being  involved.  It  should  be  remembered, 
always,  that  these  conditions  may  develop  in  children  as  a  result  of  syphilis 
and  that,  in  that  event,  they  have  a  relatively  good  prognosis.  Compres- 
sion myelitis,  a  paralysis  of  the  cord  due  to  pressure  and  usually  dependent 
upon  tuberculous  disease  of  the  vertebral  column,  is  more  common.  In 
mild  cases  it  may  cause  pain  in  the  trunk  and  back,  weakness  of  the  legs, 
and  exaggerated  patellar  reflexes.  In  more  severe  cases  the  legs  and  the 
sphincters  are  paralyzed,  the  sensory  functions  are  impaired,  and  there  is  a 
tendency  to  decubitus.  Where  a  convexity  of  the  spine  indicates  spondy- 
litis  the  disease  is  readily  recognized.  The  nervous  symptoms  and  particu- 
larly the  pain  may  be  the  only  early  indications  of  the  disease,  and,  then,  a 
careful  examination  of  the  vertebral  column,  with  the  aid  of  the  Roentgen 
ray  and  with  due  consideration  of  the  rigidity  of  the  neck  and  back  and  the 
local  tenderness  upon  pressure,  etc.,  is  essential.  The  treatment  is  surgical. 

Landry's  paralysis,  in  so  far  as  it  is  dependent  upon  disease  of  the 
spinal  cord,  is  an  acute  ascending  poliomyelitis. 

2.  TABES  DORSALIS 

Tabes  dorsalis,  the  typical  gray  degeneration  of  the  posterior  roots,  not 
infrequently  has  its  beginning  in  the  later  years  of  childhood  and  is,  in  all 
probability,  invariably  due  to  hereditary  syphilis.  Its  onset  and  course  are 
insidious,  resembling  in  a  general  way  its  progress  in  the  adult.  The  ataxia 
and  the  consequent  disturbances  of  locomotion  are  less  prominent  and  the 
patellar  reflexes  are  not  always  lost  in  childhood.  A  cardinal  symptom  is 
the  failure  of  the  pupil  to  react  to  light  and,  associated  with  this,  lancinating 
pains,  headache,  optic  atrophy,  and  urinary  incontinence  are  observed. 
Headache  and  enuresis  are  especially  early  symptoms.  Gastric  crises  and 
arthropathies  sometimes  occur.  One  sex  is  affected  as  frequently  as  the  other. 

The  development  of  progressive  paralysis  is  comparatively  rare.  The 
disease  usually  terminates  fatally  after  puberty  is  established.  Mercurial 
treatment  is  of  no  avail.  If  the  optic  atrophy  appears  early,  as  it  commonly 
does,  the  patient  should  be  placed  in  an  institution  for  the  blind. 

3.  TUMORS  OF  THE  CORD 

Tubercles  and  gliomata  of  the  cord  are  found  in  children.  Sarco- 
mata of  the  spinal  meninges  are  more  important,  because  they  are  often 


522  TEXT-BOOK  OF  PEDIATRICS 

amenable  to  surgical  treatment.  Their  symptoms  are  frequently  ush- 
ered in  by  pain  and  even  by  unilateral  paralyses  of  the  Brown-Sequard 
type.  In  the  differential  diagnosis,  spondylitis  and  syphilis  of  the  cord 
should  always  be  considered. 

XIII.  ENDOGENOUS   OR  HEREDITO-FAMILIAL  DISEASES   OF 
THE  NERVOUS  AND  MUSCULAR  SYSTEMS 

The  heredito-familial  or  heredito-degenerative  diseases  of  the  nervous 
system,  in  the  strict  sense  of  these  terms,  give  a  characteristic  history. 
They  usually  affect  several  members  of  a  single  generation;  they  may  be 
transmitted  through  successive  generations;  they  may  arise  without 
apparently  external  cause;  and,  as  a  rule,  they  progress  without  inter- 
ruption. The  identical  type  of  disease  is  usually  repeated  in  the  given 
family  and  even  its  peculiarities  and  the  age  at  which  its  first  manifesta- 
tions appear  in  the  members  of  a  given  generation  are  practically  the  same. 
External  injuries  or  infectious  diseases  may  occasionally  cause  a  premature 
development.  In  each  succeeding  generation  the  onset  of  the  disease  is  apt 
to  occur  at  an  earlier  age.  Not  all  the  members  of  a  family  are  necessarily 
affected  by  the  disease,  but  even  the  healthy  may  transmit  the  idiosyncrasy 
to  their  progeny.  In  all  this  group  of  diseases,  sporadic  or  so-called  erratic 
cases  occasionally  appear  outside  of  the  distinctly  familial  line.  This  possi- 
bility is  always  to  be  considered  if  a  clinical  picture  presents  features  which 
isolate  it  from  the  symptom-complexes  of  non-hereditary  disease. 

The  basic  etiology  of  these  diseases  is  shrouded  in  obscurity.  Possibly 
alcoholism,  conception  during  intoxication,  great  differences  in  the  age  of 
the  parents,  their  consanguinity,  or  their  advanced  age  may  play,  each  of 
them,  a  causal  part.  When  the  disease  has  once  made  its  appearance  in  a 
family  there  can  be  no  doubt  that  a  germ-injury  results  which  is  trans- 
mitted to  the  offspring,  who  are  born  with  a  nervous  system  in  which  some 
of  the  tracts  or  nuclei  are  deficient  or  deteriorate  after  a  certain  length  of 
time;  they  succumb,  in  fact,  to  a  premature  senility  (Jendrassik)  used  up  by 
functional  demands  upon  them  and  lacking  the  capacity  for  the  normal 
repair  or  regeneration  which  occurs  in  healthy  organisms. 

Pathologic  Anatomy. — In  the  pathologic  anatomy  of  these  diseases  no 
inflammatory  processes  are  discoverable.  On  the  contrary,  aplasia,  atrophy, 
degeneration,  affecting  certain  nerve  paths  and  neuron  systems  electively, 
are  the  characteristic  features. 

The  clinical  picture  in  these  cases  presents  an  almost  indescribable 
variation.  Briefly,  in  the  following  paragraphs,  a  few  only  of  the  principal 
types  are  presented.  So  many  variations  of  these  are  possible  that  the 
exceptions,  it  may  almost  be  said,  are  more  common  than  the  rule. 

Prognosis. — In  the  individual  case,  the  prognosis  is  often  too  well 
known  from  the  family  history.  Arrest  or  improvement  is  extremely  rare. 
No  prediction  may  be  safely  made  that  any  one  member  of  a  family  will 
be  spared  by  the  affliction.  Not  until  the  critical  age,  at  which  other 
members  of  the  family  have  succumbed,  has  been  passed,  may  any  hope 
be  entertained. 


DISEASES  OF  THE  NERVOUS  SYSTEM  523 

Prophylaxis. — As  a  matter  of  prevention,  the  question  of  weaning  an 
infant  from  a  mother  who  comes  of  an  affected  family  and  substituting  a 
healthy  wet-nurse  may  be  considered.  Any  measures  which  tend  to  spare 
the  nervous  system  from  strain  and  to  avoid  all  excessive  muscular  exertion 
may  be  considered  prophylactic  and  are  probably  more  useful,  when  the 
disease  is  fully  developed,  than  the  forced  demands  of  gymnastic  exercise 
swimming,  sports,  etc. 

Treatment. — The  treatment  of  these  disorders  fills  an  unsatisfactory 
chapter  in  medicine.  Recourse  can  only  be  had  to  symptomatic  measures 
and  to  the  attempt  at  the  psychic  influence  of  both  parents  and  children. 
If  for  no  other  reason,  school  attendance  and  intercourse  with  other  children 
are  to  be  recommended.  For  the  rest,  intelligent  resort  may  be  had  to  such 
physical  methods  of  treatment  as  massage,  hydrotherapy,  baths,  electri- 
city, etc. 

1.  AMAUROTIC  FAMILIAL  IDIOCY  (TAY-SACHS'  IDIOCY) 

This  interesting  condition  affects  exclusively  children  of  Jewish  descent. 
The  onset  of  the  disease  is  usually  observed  in  the  second  year.  The  child, 
hitherto  healthy,  cheerful,  and  well-developed,  becomes  quiet  and  sleepy 
while  the  attentive  parent  notices  the  beginning  of  an  impairment  of  vision. 
The  patient  no  longer  follows  bright  objects  with  the  eyes.  An  ophthal- 
moscopic  examination  of  the  fundus  reveals  the  pathognomonic  feature  of 
the  disease,  a  grayish-white  discoloration  in  the  region  of  the  macula  lutea, 
larger  than  the  papilla,  and  at  its  centre,  in  place  of  the  fovea  centralis,  a 
cherry-red  or  rust-colored  spot.  The  optic  nerve  shows  more  or  less  atrophy 
and  becomes  increasingly  atrophic  with  the  course  of  the  disease.  Nystag- 
mus, inequality  of  the  pupils  and  strabismus  may  also  appear 

With  the  rapidly  increasing  loss  of  sight,  to  which  deafness  is  usually 
added,  a  rapid  deterioration  of  all  the  mental  functions,  approaching  com- 
plete idiocy,  makes  its  appearance.  Simultaneously,  a  progressive  muscular 
weakness  develops.  The  head  is  bowed  flaccidly  upon  the  breast,  the  limbs 
become  more  and  more  powerless,  until  they  present  the  picture  of  complete 
bilateral  paralysis.  Usually  they  are  atonic,  but  occasionally  become 
spastic.  The  child  dies  by  the  end  of  the  second  or  third  year  of  life. 

Pathologic  Anatomy. — 'No  marked  anomalies  are  demonstrable  macro- 
scopically,  but  the  microscopic  findings  are  typical  of  the  disease  (Schaffer, 
Vogt).  The  entire  central  gray  matter  of  the  nervous  system  shows  degen- 
erative changes.  The  ganglion  cells  are  distended  and  present  characteristic 
structural  alterations,  revealed  by  staining  methods,  into  which  we  cannot 
enter  here.  The  cells  of  the  nuclear  layer  of  the  retina  show  similar  changes. 

Diagnosis. — The  findings  in  the  macula  lutea  are  pathognomonic,  but 
have  been  absent  in  several  cases. 

JUVENILE  AMAUROTIC  FAMILIAL  IDIOCY 

At  a  later  age,  a  familial  form  of  the  disease  appears  which  presents  so 
many  analogies  to  the  infantile  type  that,  with  Vogt,  we  may  look  upon  it  as 
a  juvenile  phase  of  the  same  malady.  This  conclusion  is  confirmed  by  the 


524  TEXT-BOOK  OF  PEDIATRICS 

microscopic  pathological  findings  in  the  central  nervous  system,  which 
consist  in  a  diffuse  degenerative  process  in  the  ganglion  cells  and  bears  a 
strong  resemblance  to  that  which  is  found  in  the  Tay-Sachs'  type.  The 
onset  of  the  disease  is  postponed  until  the  fourth  to  the  sixteenth  year;  it  is 
of  longer  duration;  but  it  similarly  results  in  blindness,  diplegic  paralysis, 
progressive  mental  decline,  and  death.  The  main  clinical  difference  is  in 
the  abscence  of  typical  findings  in  the  macula  lutea  and  the  development  of 
a  simple  optic  atrophy,  even  with  a  normal  papilla.  The  blindness  in  these 
cases  is  probably  entirely  central,  a  fact  which  may  obtain  in  the  infantile 
Tay-Sachs '  form.  The  Hebrew  race  furnishes  a  majority  of  these  later  cases 
but  not  to  so  exclusive  a  degree  as  in  the  infantile  type. 

2.  FAMILIAL  CEREBRAL  DIPLEGIAS  AND  FORMS  OF  CEREBROSPINAL  DISEASE 

The  familial  cerebral  diplcgias  present  clinical  pictures  which  may 
resemble  very  closely  simple  cerebral  diplegia,  or  Little 's  disease.  The  usual 
symptom-complex  of  spasticity,  with  ultimate  involvement  of  the  cranial 
nerves,  and  with  mental  disturbance,  generally  presents  itself.  To  this 
relatively  simple  picture,  however,  is  added  a  most  variable  combination 
of  symptoms,  absent  or  at  least  uncommon  in  the  true  cerebral  diplegias. 
These  include  tremor,  ataxia,  optic  atrophy,  bulbar  disturbances,  brady- 
lalia,  idiotic  laughter,  loss  of  sphincteric  control,  and  muscular  atrophy  or 
pseudohypertrophy.  It  is  by  this  combination  of  symptoms,  by  its 
gradual  and  late  onset,  now  in  early  childhood  and  again  in  established 
puberty,  and  by  its  slow  but  surely  aggravated  progress,  that  the  disease 
should  be  distinguished,  even  in  isolated  cases,  from  the  congenital  or  post- 
natal, exogenous,  cerebral  diplegias  of  infancy.  Its  familial  occurrence 
alone  is  not  sufficient  argument  for  a  diagnosis,  since  true  Little's  disease, 
caused  by  birth  traumata,  has  been  repeatedly  recorded  of  successive 
members  of  a  family. 

The  history  of  familial  diplegia  in  a  given  family,  despite  of  numerous 
individual  variations,  shows  that  the  disease  remains  true  to  type  and  pre- 
sents fairly  similar  pictures  in  each  group.  It  extends  commonly  over  years 
and  even  decades  of  time. 

3.  DISEASES  OF  THE  MYOSTATIC  SYSTEM 

1.  Pseudosclerosis  and  progressive  lenticular  degeneration  (Wilson's 
disease) .  The  onset  of  this  group  of  extremely  interesting  diseases  usually 
dates  back  to  late  childhood.  The  group  includes  isolated  or  familial  cases 
of  diseases  due  to  a  pathologic  condition  of  the  extra-pyramidal  tracts  and, 
in  true  Wilson 's  disease,  of  the  lenticular  nucleus.  This  consists  of  prolifer- 
ation of  the  glia  with  atrophy  of  the  nerve  cells  and  fibres  and  later,  even 
cavity  formation.  Coincidently  there  is  found  a  cirrhosis-like  hepatic 
disease,  which,  however,  is  without  symptoms  during  life.  The  symptoms 
include  a  peculiar  mask-like  rigidity  and  hypertony  of  the  facial  muscles  and 
extremities.  Babinski's  phenomenon  is  negative  and  the  deep  reflexes  not 
exaggerated.  There  is  dysphagia,  dysarthria,  marked  slowness  of  motion 
without  paralyses,  however,  but  moderate  or  severe  tremor  and  distinct 


DISEASES  OF  THE  NERVOUS  SYSTEM  525 

psychic  changes.  Eye  symptoms  such  as  nystagmus  and  optic  atrophy  are 
absent,  as  are  also  evidences  of  cerebellar  symptoms  and  disturbances. 
In  acute  cases,  death  may  occur  after  a  few  months  but  the  more  chronic 
continue  for  several  years. 

2.  Progressive  torsion  spasm,  torsion  neurosis  or  progressive  lordotic 
dysbasia,  is  the  term  applied  to  a  disease-picture-  but  recently  described. 
The  condition  probably  depends  upon  some  organic  lesion  of  the  central 
nervous  system.  Apparently  it  occurs  chiefly  among  children  of  the  Jewish 
race  and  after  the  period  of  infancy.  It  develops  insidiously  and  progres- 
sively, is  marked  by  pulling  and  twitching  spasms,  especially  noticeable  in 
walking.  This  gives  the  patient  a  fantastic  clown-like  appearance.  The 
proximal  muscles  of  the  extremities  and  trunk  are  chiefly  involved.  The 
face  is  not  affected  and  the  intelligence  not  impaired.  In  the  matter  of 
differential  diagnosis  bilateral  athetosis  must  be  considered.  Treatment,  so 
far,  has  proved  fruitless. 

4.  HEREDITARY  ATAXIA  (FRIEDREICH'S  ATAXIA) 

The  classical  type  of  this  spinal  disease  is  characterized  by  static  and 
locomotor  ataxia,  the  absence  of  the  patellar  reflexes,  the  development  of 
nystagmus,  and  the  formation  of  a  peculiar  form  of  club-foot  with  retraction 
of  the  great  toe.  To  these  usual  symptoms,  curvature  of  the  spine  (kypho- 
scoliosis),  and  mental  disturbances  are  often  added.  The  disease  commonly 
begins  between  the  fourth  and  the  seventh  year;  it  is  gradually  progressive 
and  lasts  for  several  decades 

Another  type  of  hereditary  disease  is  presented  in  the  heredito-ataxie 
cerebelleuse  of  Marie.  In  this  form,  the  disturbance  of  coordination  has 
the  characters  of  cerebellar  ataxia.  The  gait  is  staggering,  rather  than 
stamping  or  dragging,  and  the  muscles  of  the  trunk  share  in  the  disturbance 
of  balance.  The  patellar  reflexes  are  present  and  even  exaggerated.  The 
limbs  may  be  slightly  spastic.  Nystagmus  is  rare;  but  other  disturbances 
of  the  ocular  muscles,  producing  strabismus  and  ptosis,  are  common.  Optic 
atrophy  is  observed.  Club-foot  does  not  occur.  The  disease  is  of  late 
development  and  often  after  puberty  is  established. 

Between  these  two  definite  types  there  are  all  sorts  of  transitional  forms, 
so  that  no  strict  lines  of  separation  are  possible.  Symptoms  of  other 
heredito-degenerative  nervous  disorders,  including  auditory  impairment, 
idiotic  mirth,  and  muscular  atrophy  may  be  associated,  in  individual  cases, 
with  either  type. 

Static  ataxia  not  infrequently  manifests  itself  in  constant  motor  rest- 
lessness, or  in  uninterrupted  balancing  and  oscillatory  movements  of  the 
head  and  limbs  which  resemble  tremor,  chorea  or  athetosis.  These  invol- 
untary motions  may  become  very  annoying  to  the  patient  in  walking.  The 
speech  is  usually  slow,  scanning  and  indistinct.  The  pupillary  reaction,  as 
a  rule,  is  normal. 

The  pathologic  substratum  of  the  disease  is  an  aplasia  or  degeneration 
of  varying  distribution  in  the  posterior  columns  of  the  cord  or  in  the  cere- 


526  TEXT-BOOK  OF  PEDIATRICS 

bellum.  An  atrophy  of  the  lateral  cerebellar  tracts,  the  columns  of  Clark, 
and  Gower  's  tract  may  ultimately  ensue. 

Diagnosis. — At  its  onset,  and  especially  in  those  solitary  cases  which  are 
common  in  this  disease,  its  differentiation  from  cerebellar  tumor,  brain 
syphilis,  and  even  infantile  tabes  dorsalis  may  need  consideration.  Normal 
pupillary  reactions  with  distinctly  atactic  symptoms  contraindicate  tabes. 

Treatment. — Exercises  (Frenkel),  recommended  for  tabes  are  said  to 
give  good  results  also  in  this  condition.  Considering  the  long  duration  of 
the  disease  the  method  is  not  without  good  purpose. 

5.  MUSCDLAR  ATROPHIES 

Early  Infantile  Progressive  Spinal  Muscular  Atrophy  (Werding- 
Hoffmann). — This  disease  begins  in  the  first  year  of  life  and  first  shows  itself 
in  weakness  of  the  legs.  In  succession,  the  muscles  of  the  back,  neck, 
shoulders,  and  arms  are  involved,  until  finally  the  entire  body,  with  the 
exception  of  the  facial  muscles,  is  paralyzed.  The  extension  of  the  paralysis, 
after  some  years,  to  the  respiratory  muscles  ushers  in  the  end.  The  para- 
lyzed muscles  may  exhibit  fibrillary  twitching.  Excessive  development 
of  the  adipose  layer  may  hide  the  extent  of  the  atrophy.  The  deep  re- 
flexes gradually  disappear;  the  electric  excitability  is  reduced  and,  later, 
the  reactions  of  degeneration  appear.  Speech,  general  sensation,  and  the 
control  of  the  sphincters  remain  intact. 

The  disease  is  due  to  degeneration  of  the  cells  of  the  anterior  horn  and 
the  consequent  degeneration  of  the  motor  roots  and  of  the  muscles  they 
innervate. 

Diagnosis. — The  distinction  of  this  disease  from  congenital  myatonia 
may  be  difficult.  Its  progressive  course,  the  presence  of  fibrillary  twitching, 
and  the  development  of  the  reactions  of  degeneration  are  significant  of 
muscular  atrophy.  The  disease  may  be  distinguished  from  acute  polio- 
myelitis, occurring  in  early  infancy,  by  its  insidious  approach,  its  progres- 
sive quality  and  its  familial  history. 

Progressive  Neurotic  Muscular  Atrophy,  Peroneal  Type  (Hoffmann.) — • 
In  this  disease,  appearing  commonly  in  later  childhood,  the  peroneal 
muscles  and  other  muscular  groups  of  the  legs  are  first  affected  and  show  a 
symmetrical  atrophy.  The  gait  suffers  peculiarly,  the  entire  limb  is  lifted 
high.  The  toe  drops  and  is  the  first  part  of  the  foot  to  touch  the  ground. 
This  is  the  so-called  steppage  gait.  Sensory  and  vasomotpr  disturbances  are 
often  associated  with  these  motor  phenomena.  The  electrical  reactions 
may  be  reduced  or  altered  even  in  apparently  normal  muscles.  The  deep 
reflexes  gradually  disappear  and  fibrillary  twitching  in  the  atrophic  areas 
is  common.  The  muscles  of  the  forearm  and  hand  may  become  affected 
in  precisely  the  same  manner  as  those  of  the  leg,  leading  to  the  deformity  of 
"claw-hands." 

The  course  of  the  disease,  broken  by  pauses  and  remissions,  may  extend 
over  a  number  of  years.  Its  structural  basis  is  a  degeneration  of  the  per- 
ipheral nerves  supplying  the  affected  areas,  although  changes  are  also  found 
in  the  spinal  cord,  particularly  in  the  column  of  Goll.  Cases  have  been 


DISEASES  OF  THE  NERVOUS  SYSTEM 


527 


recorded  in  which  the  nerves  were  palpable  as  thick  strands,  incident  to  an 
hypertrophy  of  their  connective  tissue  (Dejerine-Sottas.)  Since  the  dis- 
ease is  very  chronic,  orthopedic  methods,  by  way  of  tendon  transplanta- 
tion, etc.,  may  sometimes  prove  beneficial. 

Progressive  Muscular  Dystrophy.  —  This  is  a  purely  muscular  disease. 
In  many  individual  cases  a  number  of  muscle  groups  atrophy  and 
degenerate  in  rather  characteristic  grouping  and  succession.  The  atrophy 
may  be  preceded  by  a  seeming  hypertrophy  of  the  muscles.  But  these 
excessively  large  muscles  are  weak  and  flabby.  Their  apparent  increase  in 
size  is  the  result  of  a  proliferation  of  the  fatty  and  connective  tissue  ele- 
ments, a  pseudohypertrophy,  or  lipomatous  pseudohypertrophy.  Electri- 
cal examination  shows  no  reaction  of  degeneration;  as  a  rule  fibrillary 
twitching  is  also  absent,  the  reflexes  are,  at  most,  reduced.  Disturbances 
of  sensation  and  loss  of  sphincteric 
control  do  not  occur.  Deformities 
of  the  feet  develop  occasionally.  The 
weakness  of  the  gluteal  lumbar  and 
dorsal  muscles,  frequently  involved, 
gives  a  characteristic  clinical  picture, 
the  features  of  which  are  a  peculiar 
waddling  gait,  a  more  or  less  high- 
grade  lordosis,  and  a  peculiar  diffi- 
culty in  stooping  or  rising  from  a 
recumbent  position.  In  fact,  children 
accomplish  these  movements  only 
by  the  aid  of  their  hands  with 
which  they  climb  up,  as  it  were, 

On  themselves. 

.     *«  eeven-year-o        oy.        seuoyperropy   o        e 

The    major    number    Of     Cases     Of  muscles  of  the  nates  and   calves.     Difficulty   in 

i          ,  ,        ,         .        .          i'ii  rising  to  an  upright  position  on  account  of  the 

niUSCUlar  dystrophy    begin    in    Child-  weakness  of  the  muscles  of  the  back. 

hood  and  not  infrequently  as  early 

as  the  first  year.  The  disease  continues  over  many  years  and  death  is  often 
due  to  tuberculosis.  A  more  minute  description  of  the  various  types  of 
this  malady  is  to  be  found  in  the  text-books  on  medicine  or  neurology  and, 
therefore,  may  be  omitted  here. 

The  demonstration  of  hypertrophy,  the  absence  of  fibrillary  twitching, 
of  the  reactions  of  degeneration  and  of  sensory  disturbances,  are  important 
in  the  diagnosis,  as  is  also  the  freedom  from  disease  of  the  hand  and  the  fore- 
arm and  the  normality  of  the  patellar  reflex.  With  these  means  of  identi- 
fication, its  distinction  from  acute  poliomyelitis,  neurotic  muscular  atrophy, 
and  myatonia  should  be  a  ready  one.  The  possibility  of  its  confusion  with 
congenital  dislocation  of  the  hip  and  coxa  vara,  which  may  induce  similar 
perversions  of  gait,  should  be  noted.  In  this  event  the  Roentgen  picture  is 
of  value.  The  muscular  hypertrophy  of  Thomson  's  disease  may  be  definitely 
distinguished  by  careful  observation  of  the  functional  disorder  of  the 
muscles  and  by  the  evidence  of  the  myotonic  reaction.  Combinations  of  the 
two  diseases,  however,  have  been  described. 


FIG.    136.  —  Progressive     muscular    dystrophy, 
eleven-year-old  boy.      Pseudohypertrophy   of  the 


528 


TEXT-BOOK  OF  PEDIATRICS 


6.  UNCOMMON  FORMS 

Besides  the  forms  of  disease  briefly  described,  there  are  other  hereditary 
familial  conditions  which  occasionally  occur  in  children.  Hereditary 
spastic  spinal  paralysis,  amyotrophic  lateral  sclerosis,  progressive  bulbar 
paralysis,  progressive  ophthalmoplegia,  Huntington's  chorea  or  chronic 
progressive  chorea,  essential  hereditary  tremor,  familial  paralysis  agitans, 
hereditary  optic  atrophy,  general  neurofibromatosis  or  von  Reckling- 
hausen  's  disease,  progressive  degeneration  of  the  lenticular  nucleus,  among 
others,  may  be  mentioned.  Congenital  myotonia  or  Thomsen  's  disease  may 
also  appear  during  childhood  or  even  in  infancy. 

XIV.  DISEASES  OF  THE  PERIPHERAL  NERVOUS  SYSTEM 

1.  PARALYSES 

The  peripheral  paralyses  show,  in  a  general  way,  the  same  relations  and 
demand  the  same  treatment  as  in  the  adult.  But  a  brief  description, 

therefore,  of  their  special  features 
will  be  necessary. 

Facial  paralysis  is  very  com- 
mon among  children  and  partic- 
ularly so  in  infancy.  It  may  be 
of  congenital  origin  and  due  to  a 
congenital  absence  of  the  nucleus 
(see  page  488),  but  not  infre- 
quently it  is  the  result  of  trauma 
from  the  use  of  the  forceps  in 
delivery  or  from  extracranial 
pressure  during  passage  through 
the  pelvic  outle't.  Most  fre- 
quently of  all  it  results  from  ear 
infections  and  especially  from 
tuberculous  disease  of  the  mas- 
toid.  (Fig.  137.)  It  may  also 
be  a  manifestation  of  acute  pol- 
iomyelitis localized  in  the  pons, 
an  origin  always  probable  in  the  so-called  rheumatic  forms.  It  occurs,  too, 
as  a  post-diphtheritic  symptom. 

Paralyses  of  the  serratus,  the  radial,  the  median,  the  peroneal  nerves, 
etc.,  are  occasionally  seen  as  the  results  of  traumata,  infective  diseases 
and  certain  forms  of  poisoning.  Birth  palsies  are  discussed  elsewhere  in 
this  volume. 

A  rather  common  event  in  childhood,  up  to  the  fifth  year,  is  the  painful 
paralysis  of  the  arm — the  paralysie  douloureuse  of  Chassaignac.  When  the 
arm  is  wrenched,  as  in  lifting  a  child  by  the  hand  or  sustaining  him  when  he 
stumbles,  the  member  may  be  seized  with  intense  pain  and  drop  in  pronation 
as  though  paralyzed.  All  motion  is  shunned,  although  careful  observation 
reveals  no  paralysis  whatever.  All  passive  movements  can  be  performed, 


FIG.  137. — Right  sided  peripheral  paralysis  of  the 
facial  nerve  as  a  result  of  tuberculosis  of  the  right  mas- 
toid,  six-month-old  child. 


DISEASES  OF  THE  NERVOUS  SYSTEM  529 

but  the  child  objects  and  cries  out,  particularly  when  any  attempt  at 
supination  of  the  forearm  is  made.  This  is  not  a  neurosis,  but  a  derange- 
ment interne,  a  disturbance  of  the  joint,  a  subluxation  of  the  head  of 
the  radius. 

Treatment  consists  in  forcible  stretching,  supination,  and  complete 
flexion  of  the  forearm.  This  relieves  the  condition  at  once.  In  some  cases, 
psychic  limitations  must  be  overcome  by  encouraging  the  child  to  reach  for 
desired  articles,  the  well  arm  being  bandaged,  if  necessary,  to  restrain  its 
preferential  use. 

2.  NEURALGIA 

Occipital  and  trifacial  neuralgias  are  practically  the  only  forms  which 
occur  in  children  of  school  age.  Usually  these  appear  in  children  with 
neuropathic  stigmata.  Nerve  pressure  points  may  be  very  distinct.  Etio- 
logically,  coryza,  influenza  and,  in  rare  instances,  malaria  are  in  relation  to 
the  disorder.  Errors  in  refraction  must  sometimes  be  causally  considered. 

Therapeutically  much  may  be  accomplished  by  regulation  of  the  mode 
of  living,  avoidance  of  eye-strain,  especially  by  lamplight,  exercise  in 
the  open,  attention  to  the  action  of  the  bowels,  etc.  The  fitting  of  eye- 
glasses, the  removal  of  adenoids  and  the  treatment  of  chronic  nasal  dis- 
order's are  frequently  remedial.  Internally,  a  course  of  treatment  with 
arsenic  is  often  useful.  During  the  acute  attack,  quinine,  antipyrin,  and 
other  similar  remedies  may  be  tried,  but  care  must  be  exercised  to  prevent 
their  abuse.  The  daily  application  of  weak  anodal  currents,  for  two  or 
three  weeks,  may  give  permanent  results. 

3.    POLYNEURITIS 

The  most  frequent  form  of  this  malady,  post-diphtheritic  paralysis,  is 
discussed  under  the  head  of  the  primary  disease.  Other  forms  of  poly- 
neuritis  are  extremely  rare  in  children.  It  may  develop  in  relation  to  any 
of  the  infectious  diseases  or  to  certain  forms  of  chemical  poisoning.  Lead, 
arsenic,  sometimes  in  its  therapeutic  use,  and  alcohol  must  be  considered  in 
this  connection. 

The  course,  prognosis  and  treatment  are  the  same  as  in  the  adult.  The 
differentiation  from  acute  poliomyelitis  is  discussed  briefly  on  page  517. 

XV.  DISEASES  OF  THE  MUSCLES 

Congenital  muscular  defects,  congenital  muscular  atony,  and  muscular 
dystrophy  have  been  already  discussed.  Other  diseases  of  this  class  are  so 
uncommon  that  the  mere  mention  that  they  occur  in  childhood  must 
suffice.  Occasionally  we  meet  with  myoplegia  periodica,  myasthenia 
pseudoparalytica,  polymyositis  which  may  be  primary  or  may  result  from 
an  invasion  of  the  Trichina,  and  finally  with  progressive  myositis  ossificans, 
.a  rare  condition,  but  one  which  almost  always  begins  in  childhood. 
34 


530  TEXT-BOOK  OF  PEDIATRICS 

FUNCTIONAL  DISEASES  OF  THE  NERVOUS  SYSTEM 

I.  CONVULSIVE  DISEASES 

1.  SPASMOPHILIA  OR  THE  SPASMOPHILIC  DIATHESIS 

Laryngospasm,  Tetany  and  Eclampsia. 

Spasmophilia  is  a  condition  of  hyper-irritability  of  the  nervous  sys- 
tem peculiar  to  early  life,  indicated  by  excessive  electrical  or  mechanical 
reactions  of  the  peripheral  nerves  and  by  the  tendency  to  tonic  and 
clonic  convulsions. 

Spasmophilia  is  an  extraordinarily  common  disease  in  early  childhood. 
It  represents  the  major  part  of  the  convulsive  disorders  of  children,  includ- 
ing laryngospasm.  It  may  exist  for  weeks  and  months  in  the  apparently 
healthy  without  arousing  the  attention  of  parents  or  physician  by  any 
threatening  manifestations.  At  certain  seasons  of  the  year  the  disturbing 
evidences  of  the  spasmophilic  diathesis  may  be  demonstrated  in  a  large 
percentage  (thirty,  or  more  per  cent.),  of  all  infants.  Timely  attention  to 
this  latent  condition  is  of  great  importance,  since  therapeutic  measures  are 
possible,  in  many  a  case,  which  will  suffice  to  avert  the  paroxysmal  mani- 
festations threatening  the  child. 

The  discussion,  therefore,  should  be  confined  initially  to  the  distinctive 
characteristics  of  the  spasmophilic  state,  sometimes  described  as  latent 
tetany  or  the  tetanoid  condition.  Its  most  certain  and  constant  sign,  which 
may,  indeed,  be  considered  pathognomonic,  is  the  fact  of  electrical  hyper- 
irritability,  the  so-called  Erb's  phenomenon.  This  sign  was  discovered  by 
Escherich  and  has  been  especially  studied  by  Mann  and  Thiemich.  The 
most  valuable  results  of  these  important  researches  is  the  demonstration 
that  in  Spasmophilia  the  kathode  opening  contraction,  ordinarily  produced 
in  infants  only  with  currents  in  excess  of  five  milliamperes,  appears  with 
weaker  currents,  ranging  down  from  four  or  three  to  even  one  milliampere, 
or  less. 

For  practical  purposes  this  one  estimation  is  generally  sufficient.  In 
most  spasmophilic  infants,  even  when  they  are  very  small,  the  reaction  may 
be  obtained  without  an  anesthetic.  During  a  convulsion,  however,  partic- 
ularly in  children  of  three  months  or  less,  difficulties  are  frequently 
encountered.  The  hand  is  often  closed  go  firmly  that  the  contractions 
cannot  be  determined. 

The  test  is  made  by  placing  the  negative  electrode  on  the  breast  or  abdo- 
men, while  the  positive,  in  the  form  of  Stintzmg's  normal  electrode,  three 
centimeters  square,  is  placed  over  the  median  nerve  in  the  elbow.  If 
necessary,  the  results  may  be  obtained  over  the  ulnar  or  the  peroneus.  In 
determining  the  minimal  contraction  it  is  customary  to  begin  with  the  weak- 
est current,  for  under  conditions  of  hyper-irritability  stronger  currents  will 
often  produce  a  kathodal  closing  tetanus,  which  usually  obscures  the  recog- 
nition of  the  opening  contraction.  With  a  little  practice  the  voluntary 
movements  of  the  child  may  be  easily  distinguished  from  the  reaction  to  the 
opening  and  closing  of  the  circuit.  Every  kathodal  opening  contraction 


DISEASES  OF  THE  NERVOUS  SYSTEM  531 

determined  in  this  manner,  with  a  current  of  less  than  five  milliamperes 
indicates  spasmophilia. 

The  determination  of  mechanical  hyper-irritability  is  an  easier  matter, 
if  less  reliable.  It  is  manifested  by  lightening-like  contractions,  resembling 
those  produced  by  stimulating  the  nerve  electrically,  whenever  the  per- 
ipheral nerve  trunks  are  tapped  with  the  pleximeter.  This  occurs  most 
readily  in  the  case  of  the  facial  nerve.  Tapping  the  cheek  even  with  the 
finger,  brings  out  this  lightning-like  contraction  of  all  the  facial  muscles,  the 
facialis  phenomenon,  or  Chvostek's  sign.  When  the  child  laughs  or  cries,  in 
a  word  whenever  the  facial  muscles  are  under  nerve  control,  the  sign  cannot 
be  developed.  Direct  idiomuscular  contractions,  especially  in  very  young 
infants,  may  simulate  the  phenomenon.  A  contraction  which  can  be  pro- 
duced by  the  nerve  alone  is  conclusive,  as  for  instance  the  contraction  at 
the  outer  canthus  of  the  eye  when  the  masseter  is  sharply  tapped.  In 
infancy  the  facialis  phenomenon  is  of  great  value  and  may  save  all  the 
trouble  of  electrical  examination.  In  older  children  it  is  hardly  to  be  con- 
sidered a  certain  indication  of  a  spasmophilic  diathesis.  The  facialis 
phenomenon,  however,  may  be  indefinite  or  altogether  absent.  It  is  often 
possible,  in  this  event,  to  produce  a  very  distinct  radial  or  peroneal  response 
by  tapping  the  stimulation  points  of  these  nerves  in  the  arm  and  at  the 
head  of  the  fibula.  These  tests  are  recommended  in  all  doubtful  cases. 
They  are  particularly  successful  in  slightly  emaciated  infants.  In  any  case, 
they  are  reliable  only  when  voluntary  motion  has  ceased. 

Another  pathognomonic  sign  is  the  Trousseau  phenomenon,  a  test, 
however,  which  is  frequently  lacking.  At  times,  its  application  is  very 
painful  and  hence  it  is  dangerous  in  children  who  are  disposed  to  laryngo- 
spasm,  on  account  of  the  resultant  excitement.  The  Trousseau  phenomenon 
consists  in  the  artificial  production  of  a  tetanic  spasm  of  the  hand  by  com- 
pression of  the  vascular  and  nerve  structures  in  the  bicipital  groove.  It  is 
best  done  by  the  use  of  an  elastic  band  placed  around  the  arm  (Fig.  138), 
which  must  be  left  in  place  for  two  or  three  minutes.  In  infants  the  classical 
"obstetric  position"  of  the  hand  does  not  always  appear.  The  test  is 
positive  only  when  the  hand  becomes  firmly  fixed  in  a  spasmic  position, 
similar  to  this,  from  which  it  can  be  released,  even  by  passive  efforts, 
with  difficulty. 

Etiology  and  Pathogenesis. — Several  etiologic  factors  are  recognized 
which  play  a  part,  in  the  development  of  spasmophilia.  Heredity  deserves 
first  mention.  Convulsions  and  particularly  laryngospasm,  are  often 
familial  afflictions.  The  history  frequently  shows  its  appearance  in  the 
parents  and  brothers  and  sisters  of  the  patient.  The  facialis  phenomenon 
may  often  be  demonstrated  in  the  mother.  The  view  that  spasmophilia 
may  develop  upon  the  basis  of  a  neuropathic  constitution  may  be  estab- 
lished in  many  cases. 

The  disorder  has  a  very  obvious  dependence  upon  seasonal  change. 
The  number  of  manifest  and  even  of  latent  cases  rises  in  the  winter  and 
spring  months,  and  reaches  its  maximal  point  from  March  to  May.  The 
respiratory  injury  which  results  from  continuous  living  in  poorly  venti- 


532 


TEXT-BOOK  OF  PEDIATRICS 


lated  quarters  is  generally  held  to  be  responsible  for  this  prevalence,  which 
is  similarly  shown  in  rickets  (Kassowitz). 

A  third  and  very  remarkable  factor  is  the  dietary.  Breast-fed  children 
almost  invariably  escape  this  disease.  Children  fed  upon  cow's  milk 
recover  from  the  disorder  when  they  are  placed  on  human  milk.  Discon- 
tinuance of  cow's  milk  often  results  in  abatement  of  the  electrical  hyper- 
excitability;  which  immediately  reappears 
when  cow's  milk  is  again  given.  Other 
dietetic  variants  of  irritability  may  be 
demonstrated,  but  there  is  no  doubt  that 
in  many  children  a  very  special  influence 
attaches  to  cow's  milk.  Further,  it  has 
been  shown,  in  a  number  of  instances,  that 
neither  the  casein  nor  the  fat,  but  rather 
the  whey,  is  responsible  for  this  untoward 
action  (Finkelstein). 

The  age  of  the  child  has  a  bearing, 
since  spasmophilia  rarely  makes  its  ap- 
pearance earlier  than  the  fourth  month. 
Its  manifestations  are  most  frequent  from 
the  sixth  to  the  fourteenth  month.  They 
are  relatively  common  after  the  second 
year.  Premature  infants  show  a  special 
predisposition  to  the  diathesis. 

Infectious  diseases  of  all  kinds  may 
not  only  aggravate  preexisting  tendencies 
and  in  paroxysmal  form,  but  they  may 
excite  renewed  manifestations  in  cases  in 
which  the  hyper-irritability  had  subsided. 
It  is  a  well-known  fact  that  disturbances 
of  digestion  and  nutrition  may  play  a  part 
in  provoking  spasmophilia.  Indeed,  the 
disease  was  formerly  regarded  as  an  auto- 
intoxication arising  from  the  stomach  or 
intestinal  tract. 

That,  in  a  majority  of  cases,  spasmo- 
philia, is  associated  with  rickets  is  well 
established;  nor  can  there  be  any  doubt 
that  a  close  relationship  between  them 
exists.  The  greater  frequency  of  both  of  these  diseases  in  the  spring,  the 
rarity  of  spasmophilia  in  countries  which  are  free  from  rickets  (Japan), 
the  similarity  of  the  metabolic  disturbances  each  presents,  the  combina- 
tion of  tetany  with  late  rickets,  and  the  beneficial  therapeutic  effects  of 
phosphorus  and  cod-liver  oil  in  both  conditions,  all  tend  to  emphasize 
this  relationship. 

No  characteristic  structural  changes  have  been  discovered  in  post- 
mortem examinations  of  the  central  nervous  system  in  cases  of  spasmophilia 


FIG.  13S. — Tetany  in  late  rickets  (seven- 
year-old  boy).  Trousseau's  phenomenon 
persisting  on  the  left  after  removing  the 
constricting  band.  Rapid  recovery  under 
treatment  with  phosphorous  and  cod- 
liver  oil. 


DISEASES  OF  THE  NERVOUS  SYSTEM  533 

or  tetany.  Attempts  have  been  made  to  reach  a  better  understanding  of 
the  nature  of  the  disease  by  the  study  of  its  metabolism.  The  toxin  sus- 
pected and  sought  for  has  not  been  found,  but  the  more  recent  researches 
have  discovered  anomalies  in  the  metabolism  of  the  minerals.  Quest  has 
shown  that  the  brain  of  the  spasmophilic  child  contains  less  calcium  than 
the  brain  of  the  normal  infant  and  in  metabolic  experiments  spasmophilic 
children  show  a  negative  calcium  balance  (v.  Czybulsky,  Schabad). 
It  is  by  no  means  certain  that  these  anomalies  of  the  calcium  metabolism 
are  in  the  nature  of  the  cause  of  tetany;  according  to  Pexa's  very  recent 
reports,  indeed,  it  seems  improbable.  That  the  metabolism  of  the  alkalies 
and  especially  of  potassium,  deserves  special  consideration  is  suggested  by 
other  researches  (Aschenheim,  Lust).  The  theory  of  the  parathyroid  epithe- 
lial bodies,  supported  mainly  by  Escherich,  is  very  interesting.  This  theory 
places  the  responsibility  for  the  entire  disease  upon  structural  (hemor- 
rhagic),  or  functional  injuries  of  the  epithelial  bodies  lying  in  the  tissues 
surrounding  the  thyroid.  It  is  known  that  the  extirpation  of  these  bodies 
may  produce  true  tetany  and  may  affect  the  calcium  metabolism  similarly 
with  the  alteration  it  shows  in  children  suffering  with  tetany.  Nevertheless, 
it  appears  that  numerous  histologic  examinations  of  these  epithelial  bodies, 
of  very  recent  date,  do  not  support  this  theory.  Still  more  lately  the  cause 
of  the  disease  has  been  attributed  to  functional  disturbances  of  the  thy- 
mus  (Lust). 

Clinical  Manifestations. — Three  principal  types  of  convulsions  may 
develop  upon  the  basis  of  the  spasmophilic  diathesis.  (1)  Laryngospasm 
or  respiratory  spasm;  (2)  eclamptic  convulsions;  and  (3)  tonic  convulsions 
of  a  manifestly  tetanic  type. 

Why  in  one  child  a  given  type  should  develop  and,  in  a  second  case, 
another  form  cannot  be  explained.  Neither  can  one  phase  be  considered  as 
an  aggravation  of  another.  Many  infants  suffer  from  laryngospasm  alone. 
In  others  it  is  combined  with  eclampsia;  and  while  there  are  children  who 
suffer  from  tonic  convulsions  alone,  there  are  cases  in  which  these  several 
forms  may  appear  interchangeably.  A  persistent  tetany,  of  demonstrable 
degree,  is  doubtless  the  most  uncommon  type  in  early  childhood. 

Severe  attacks  of  spasmophilia  are  often  preceded  by  psychic  alterations, 
clearly  evident  to  the  careful  observer.  The  child  cries  much,  scares  easily, 
is  peevish,  permits  the  approach  only  of  certain  persons,  is  unusually 
restless,  watches  everything  that  happens  in  its  vicinity  with  apprehen- 
sive manner. 

Spasm  of  the  vocal  cords;  laryngospasm;  spasm  of  the  glottis.  Mild 
spasm  of  the  glottis,  manifested  merely  as  an  audible  whooping  inspiration, 
may  often  be  heard  as  the  accompaniment  of  the  least  excitement,  as  in 
laughing  or  crying,  without  producing  any  further  trouble.  Every  sound 
of  this  kind  will  be  heard  with  suspicion  by  the  experienced  observer  and 
will  lead  him  to  make  the  proper  tests  for  the  characteristic  evidences  of 
spasmophilia.  Such  mild  degrees  of  laryngospasm  may  unexpectedly 
change  into  serious  and  even  fatal  forms  if  not  carefully  safeguarded. 
Severe  attacks  are  very  exciting  occurrences.  The  face  suddenly  grows  pale, 


534 


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the  head  falls  back  and  respiration  ceases.  The  child  makes  several  stren- 
uous, but  unsuccessful  attempts  to  get  air.  The  eyes  protrude,  the  lips 
become  purple,  and  the  face,  covered  with  a  cold  sweat,  gradually  takes  on  a 
leaden  pallor.  Consciousness  is  lost  and  a  few  twitching  movements  around 
the  mouth  and  eyelids  are  the  only  signs  of  life.  Finally,  the  limbs  relax, 
the  urine  and  stools  are  passed,  and  death  seems  inevitable.  Suddenly,  the 
spasm  relaxes  and  a  few  crowing  respirations  show  that  the  air  is  passing  the 
still  narrowed  glottis,  A  deeper  inspiration  follows,  after  a  few  minutes 
respiration  is  gradually  reestablished,  and  the  seriously  endangered  patient 
sits  up — frightened  and  exhausted,  but  otherwise  quite  as  well  as  he  was  be- 
fore the  attack.  But  laryngospasm  does  not  always  terminate  in  this  way. 
Life  may  end  in  the  midst  of  it.  The  patient  is  not  asphyxiated,  but  the 
fatal  result  is  due  to  the  stoppage  of  the  heart.  In  such  a  case  artificial 
respiration  is  hopeless. 

Again,  the  spasm  of  the  glottis  may  pass  into  an  attack  of  general 
convulsions.      In  severe  cases,  attacks  of  laryngospasm  may  follow  each 


FIG.  139. — Persisting  tetany.     Cardiac  death.      Carpopedal  spasm  persisting  after  death. 

other  rapidly.  Twenty  or  more  such  attacks  may  occur  in  twenty-four 
hours.  Milder  and  more  severe  attacks  may  alternate  with  each  other, 
just  as  the  most  variable  gradations  between  abortive  and  really  dangerous 
spasms  are  possible.  Attacks  are  generally  somewhat  less  frequent  at 
night.  The  exciting  causes  of  an  attack  consist  chiefly  in  psychic  excite- 
ment, fright,  crying,  screaming,  sudden  awakening,  and  the  rapid  ingestion 
of  a  large  meal.  A  very  dangerous  form  of  laryngospasm  is  the  so-called 
expiratory  apnoea,  a  spasmic  arrest  of  respiration  in  the  expiratory  phase, 
which  may  cause  death  very  suddenly  and  sometimes  without  attracting 
attention.  Frequently  it  will  develop  and  pass  by  entirely  unobserved, 
since  the  crowing  inspiration  which  ordinarily  warns  the  attendant  is 
lacking.  Not  uncommonly  a  rigidity  of  all  the  respiratory  muscles,  includ- 
ing the  diaphragm,  and,  at  times,  extending  to  the  entire  body  may  be 
observed  at  the  onset  of  an  attack  of  severe  laryngospasm. 

These  laryngeal  and  respiratory  spasms,  as  manifestations  of  spasmo- 
philia,  occur  almost  without  exception  in  rickitic  infants.  After  the  second 
year  they  are  practically  unknown  and  in  this  respect  they  differ  from 
tetany  and  eclamptic  convulsions. 


DISEASES  OF  THE  NERVOUS  SYSTEM  535 

Eclamptic  convulsions,  commonly  known  to  the  laity  as  fits,  spasms  or 
cramps,  consist  in  attacks  of  localized  or  general  muscular  contraction, 
attended  by  loss  of  consciousness  and  quite  resembling  epileptic  seizures. 
Slight  convulsions  often  manifest  themselves  in  mere  vacancy  or  pallor  of 
the  face,  combined  with  a  twitching  of  the  eyes  and  eyelids,  the  so-called 
"quiet  fits. "  Usually,  however,  more  extensive  muscle  groups  are  involved 
in  these  convulsions.  The  face  is  commonly  affected  and  often  all  the  limbs. 
A  unilateral  onset  is  not  infrequently  seen.  Consciousness  is  lost  from  the 
beginning,  the  pupils  do  not  react,  and  there  is  no  response  to  skin  stimu- 
lation. These  symptoms  are  rarely  preceded  by  a  tonic  spastic  condition, 
usually  combined  with  spasm  of  the  glottis.  If  the  attacks  are  severe,  they 
present  a  very  impressive  picture.  For  a  moment,  the  face  is  mask-like 
and  vacant;  the  next,  it  is  distorted  by  intense  twitchings.  The  eyes 
move  constantly  and  rapidly,  or  roll  upward  so  that  the  sclera  is  alone 
visible.  The  tongue  wags  to  and  fro.  The  lips  often  froth,  and  in  older 
children  who  have  teeth,  they  may  be  blood-stained.  The  child  lies  on  the 
bed,  the  entire  body  shaken  by  rhythmic  shocks,  giving  vent  to  groans  or 
short  sharp  sounds  produced  by  corresponding  expiratory  spasms.  The 
fontanelle  is  usually  firmly  tense  during  an  attack.  The  pulse  is  rapid  and 
irregular.  During  the  attack,  or  immediately  following  it,  the  child  often 
passes  flatus,  feces,  or  urine.  The  manifestations  of  motor  irritability 
gradually  disappear  and  the  child  falls  into  a  sleep  from  which  it  awakens 
after  a  time  very  much  exhausted.  As  a  rule  the  duration  of  these  eclamptic 
attacks  is  not  very  great,  generally  occupying  from  one-half  to  two  minutes 
and  but  rarely  extending  to  three  or  even  five  minutes.  The  convulsions, 
however,  may  follow  one  another  so  rapidly  that  a  true  status  epilepticus 
results.  In  such  cases  fever,  and  at  times,  very  high  temperature  41°  C. 
(106°  F.),  or  more,  may  develop,  probably  as  the  result  of  irritation  of  the 
thermic  centres.  Fever  is  not  found  in  any  other  form  of  spasmophilia. 

Convulsions  may  appear  once  and  never  return;  but  of  course  this  is 
not  common.  Usually  a  small  series  of  attacks  is  observed.  The  indi- 
vidual events  may  be  repeated  very  irregularly.  One  or  two  attacks  a 
day,  or  as  many  as  twenty  or  thirty  in  the  twenty-four  hours,  may  appear. 
In  themselves,  they  are  much  less  dangerous  than  the  spasms  of  the  larynx. 
In  infancy  they  are  apt  to  be  especially  frequent  in  the  course  of  acute  or 
subacute  disturbances  of  digestion,  particularly  when  there  is  much 
gaseous  distention  of  the  abdomen.  They  often  attend  the  onset  of  febrile 
diseases.  Among  older  children,  they  occur  conspicuously,  as  so-called 
occasional  spasms,  at  the  beginning  of  gastric  disturbances  or  of  such 
infections  as  measles,  varicella,  etc.  With  other  manifestations  of  spasmo- 
philia, they  are  uncommon  after  the  second  or  third  year  and  in  later 
childhood  are  rare.  It  is  possible  that  some  of  the  so-called  reflex  spasms  of 
older  children,  supposedly  caused  by  ascarides,  obstipation,  the  presence  of 
foreign  bodies,  etc.,  belong  in  this  category.  This  is  certainly  true  of  the 
teething  spasms  which  formerly  played  so  distinctive  a  role.  Many  a  case, 
believed  to  be  epileptic,  but  recovering  toward  puberty,  is  proved  by  more 
careful  study  of  its  nature  and  history  to  be  a  late  eclampsia  (Thiemich). 


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Some  of  the  repetitional  absent  fits  of  the  run-about-age  are  associated  with 
electrical  hyper-irritability  and  relational  to  spasmophilia  (see  page  548). 

Tetanic  carpopedal  spasms,  or  arthrogryposis,  consist  in  peculiar  tonic 
spasms  of  the  hand  resulting  in  the  well  known  "  obstetrician 's  hand. "  The 
phalanges  are  extended  at  an  angle  to  the  palm,  with  extreme  apposition  of 
the  thumbs,  as  shown  in  Figures  139  and  140.  If,  at  the  same  time,  the  fore- 
arm is  flexed  and  pressed  against  the  body  the  so-called  "paw  position" 
results.  The  feet  not  infrequently  maintain  a  similarly  spasmic  posture, 

as  seen  in  Figure  140.  These  tonic  con- 
tractures  usually  persist  for  hours  and 
doubtless,  in  many  cases,  are  painful.  The 
cause  of  the  individual  attacks  is  not  known. 
If  the  condition  has  persisted  for  some 
time  a  pillow-like  edematous  swelling  is 
often  seen  on  the  backs  of  the  hands 
and  feet. 

In  infancy  this  tetanic  position  of  the 
hands  is  often  not  so  typical;  the  fingers 
are  often  flexed  and,  at  times,  abducted, 
but  the  thumb  is  always  bent  inward  and 
sometimes  wedged  between  the  other  fin- 
gers. The  differentiation  between  this 
spasm  and  a  simple  closure  of  the  hand, 
fist-like,  with  the  thumb  adducted,  is  al- 
ways possible  by  a  little  careful  compar- 
ison of  the  voluntary  with  the  involuntary 
action.  The  tetany  of  the  foot  cannot 
be  mistaken. 

Other  muscle  groups  may  take  a  part  in 
the  disease-picture  of  these  tonic  convulsive 
conditions.  The  face  is  most  commonly 
affected  and,  on  account  of  the  tensity 
of  the  muscles  of  expression,  the  patient 
wears  a  troubled,  thoughtful,  or  down- 
cast, pinched  expression  (Uffenheimer's 
"tetanic  facies").  In  severe  cases,  par- 
ticularly in  older  children,  the  lips  are 

drawn  and  slightly  puckered  (the  fishmouth).  Spastic  strabismus  is  far 
from  rare.  To  all  these  symptoms  may  be  added  spasm  of  the  muscles  of 
the  neck,  resulting  in  a  fixed  opisthotonos,  and  giving  a  picture  which,  with 
possible  inequality  and  delayed  reactions  of  the  pupils,  due  to  involvement 
of  the  unstriated  musculature  of  the  iris,  may  resemble  that  of  meningitis. 

Tonic  spasms  of  the  muscles  of  the  trunk,  arms  and  legs  have  also  been 
observed.  These  are  usually  symmetrical.  Not  infrequently,  at  the  height 
of  the  disease,  micturition  is  embarrassed  by  spasm  of  the  musculature  of 
the  bladder.  Ischuria  paradoxa,  with  dribbling  of  small  quantities  of  urine 
and  coincident  retention,  may  result,  which  causes  the  progressive  disten- 


FIG.  140. — Tetany.  Obstetrician  hand. 
Edema  of  the  dorsal  surface  of  hands 
and  feet. 


537 

tion  of  the  bladder  until  it  reaches  to  the  level  of  the  umbilicus.  While  such 
symptoms  of  manifest  tetany,  lasting  for  hours  or  even  days,  may  be  inter- 
current  with  every  attack  of  laryngospasm  and  eclampsia,  continuous 
attacks  of  so-called  persistent  tetany  may  last  for  many  days  or  weeks. 
These  are  seen  most  frequently  in  cachectic  children  with  chronic  disturb- 
ances of  nutrition.  In  this  form  of  persistent  contractions  there  is  neither 
pain  nor  edema.  There  is  a  tendency  among  clinicians  to  consider  this 
persistent  tetany  as  relational  to  a  loss  of  water  or  to  molecular  changes  in 
the  tissues.  Others  regard  them  as  due  to  particularly  severe  injuries  of  the 
epithelial  bodies. 

Cardiac  Death. — In  all  forms  of  spagmophilia  sudden  death,  due  to 
stoppage  of  the  heart,  is  not  uncommon.  It  happens  most  frequently  during 
an  attack  among  children  who  suffer  with  laryngospasm  or  expiratory 
apncea,  but  occasionally  it  occurs  independently  of  any  acute  spasms.  The 
child,  who  has  just  taken  his  food,  may  be  found  dead  in  his  crib.  In  such 
cases  the  ingestion  of  a  large  quantity  of  food  seems  to  be  the  exciting  cause 
of  the  sudden  failure.  Children  in  the  status  lymphaticus  or,  more  partic- 
ularly, those  of  the  status  thymico-lymphaticus,  stand  in  special  danger 
of  this  cardiac  death.  The  author  has  recently  expressed  the  opinion  that 
these  are  cases  of  tetany  of  the  heart,  as  spasmic  phase  of  the  spasmophilic 
diathesis  affecting  the  paths  of  the  cardiac  nerve  supply,  on  either  the  vagus 
or  the  sympathetic  side. 

Under  the  name  broncho-tetany  Lederer  describes  a  condition  of  dysp- 
noea and  consequent  cyanosis,  supposed  to  be  due  to  spasm  of  the  bronchial 
musculature,  persisting  for  days  or  weeks.  This  leads  to  atelectasis  and 
edema  of  the  involved  portions  of  the  lungs  and  often  ends  fatally.  The 
clinical  symptoms  simulate  those  of  broncho-pneumonia.  The  condition 
is  said  to  be  differentiated  by  the  Roentgen  picture,  the  broncho-tetany 
showing  a  floating  cloudiness,  and  mottled  shadows  indicating  pneumonia. 

Course,  Duration,  Complications  and  Termination. — The  spasmo- 
philic diathesis  never  disappears  rapidly,  but  usually  its  individual  mani- 
festations may  be  relieved,  or  in  a  measure  curbed,  quite  quickly.  Even 
the  electrical  hyper-irritability  may  be  reduced  sometimes  to  a  normal  point 
within  a  few  days  or  weeks.  This  abatement,  however,  is  not  synonymous 
with  recovery.  One  may  be  assured  of  the  latter  only  when  the  provoca- 
tive injuries  enumerated  no  longer  call  forth  this  hyper-irritability  and  its 
symptomatic  expressions.  Frequently  has  it  been  shown  that  a  return  to 
the  use  of  the  customary  cow's  milk  mixtures  will  redevelop  the  entire 
symptom-complex.  Then  again  it  happens  that  the  disease  which,  with- 
out the  physician's  aid,  has  wholly  disappeared  during  the  summer,  will 
make  its  reappearance  in  winter  without  the  intercurrency  of  any  infection 
to  excite  the  laryngospasm  or  the  eclamptic  convulsions. 

The  course  in  each  case  is  distinctly  individual.  Not  infrequently,  the 
entire  history  is  of  a  succession  of  either  laryngospasms  or  eclamptic 
attacks.  When  the  disease  is  long  continued,  as  a  result  of  persistently 
improper  feeding,  we  generally  find  that  first  one  and  then  another  form  of 


538  TEXT-BOOK  OF  PEDIATRICS 

tetany  will  prevail.  In  such  cases  carpopedal  spasms  are  much  more  fre- 
quently found,  with  careful  observation,  than  is  generally  supposed. 

It  is  perhaps  hardly  permissible  to  speak  of  the  complications  of  spasmo- 
philia,  but  the  condition  itself  often  appears  to  complicate  other  diseases 
and  then  requires  very  special  attention.  In  this  event,  the  observation  that 
spasmophilia  frequently  causes  hyperpyretic  temperatures  (Finkelstein), 
is  of  the  utmost  consequence.  This  bears  upon  influenza,  pertussis, 
serous  meningitis  and  other  diseases,  and  admonishes  one  that,  for  this 
reason,  perspiration  producing  packs  can  be  given,  in  the  treatment  of 
such  children,  only  with  extreme  care. 

There  are  several  conditions  that  are  supposably  related  to  spasmophilia 
and  are  believed  to  be  due  to  the  same  anomalies  of  metabolism  as  are  the 
convulsions.  These  are  opacities  of  the  crystalline  lens  (cataract)  and 
symmetrical  hypoplasia  or  erosion  of  the  enamel  of  the  permanent  teeth. 
These  conclusions,  however,  rest  upon  incomplete  data. 

Systematic  inquiries  into  the  later  fate  of  eclarnptic  children  are  very 
important  in  the  correct  prognostic  evaluation  of  the  disease  (Thiemich  and 
Birk,  Potpeschnigg).  It  has  been  found  that  a  large  number  of  these 
children  later  show  signs  of  neuropathy  or  mental  defect  and  that  only  about 
one-third  of  them  continue  to  develop  with  entire  normality.  In  only 
exceptional  cases  does  true  spasmophilia  eventually  pass  into  true  epilepsy. 

Diagnosis. — The  more  important  diagnostic  points  have  been  fully 
discussed.  That  definite  electrical  hyperexcitability,  supported,  in  early 
infancy,  by  mechanical  hyper-irritability;  that  the  Trousseau  phenomenon 
and  the  occurrence  of  true  tetanic  convulsions  are  pathognomonic  will  bear 
repetition.  Laryngospasm,  on  the  other  hand,  may  appear  as  a  symptom  of 
other  diseases,  as  in  meningitis,  cerebral  sclerosis,  etc. 

It  is  weU  to  note  that  conditions  very  similar  to  laryngospasm  have 
been  recognized  in  children  who  have  passed  the  period  of  infancy  and  who 
exhibit  the  phenomena  of  so-called  " absences."  These  disturbances  do 
not  stand  in  direct  relationship  to  spasmophilia  (see  page  557).  Occa- 
sionally cases  are  seen  which  are  indubitably  spasmophilic,  but  in  which  the 
kathodal  opening  contraction  does  not  occur  with  currents  of  less  than  five 
milliamperes.  This  is  especially  true  in  children  of  less  than  three  months 
of  age.  In  later  childhood  the  pathognomonic  value  of  the  K.  O.  C.  is  not 
absolute,  while  the  predominance  of  the  A.  O.  C.  over  the  A.  C.  C.  prob- 
ably is.  A  number  of  points  in  the  differential  diagnosis  of  spasmophilia 
from  other  eclamptic  conditions  are  discussed  on  page  542. 

Treatment. — Breast-milk  feeding,  sunlight  and  fresh  air  are  the  most 
certain  prophylactics,  as  they  are  the  most  effective  remedies,  against 
spasmophilia.  They  must  be  secured,  if  possible,  in  all  cases  in  which  the 
facialis  phenomenon  or  other  signs  of  latent  tetany  are  discovered  in 
infancy.  If  artificial  feeding  is  unavoidable,  the  most  important  rules  are 
to  dimmish  the  total  dietary  and  especially  to  reduce  the  cow 's  milk  to  the 
lowest  possible  measure.  This  may  range  between  one-third  and  one-half 
litre  a  day.  It  should  be  replaced  by  carbohydrates  in  the  form  of  gruels, 
flour-pap,  or  barley  water  and,  eventually,  in  the  exclusive  form  of  malt- 


DISEASES  OF  THE  NERVOUS  SYSTEM  539 

soup.  Older  infants  may  be  transferred  to  a  mixed  dietary,  including 
vegetables,  stewed  apples,  etc.,  sooner  than  usual.  Still  older  children  may 
be  fed  adequately  upon  a  milk-free  diet  for  a  long  time,  large  quantities  of 
food  at  any  one  feeding  should  be  avoided  under  all  circumstances,  because 
of  the  danger  that  excess  may  precipitate  a  severe  attack  of  laryngospasm 
and  consequent  cardiac  death.  This  is  particularly  true  when  paroxysmal 
manifestations  have  already  appeared.  The  internal  administration  of 
phosphorus  and  cod-liver  oil,  as  directed  on  page  207,  is  always  indicated. 
If  dyspepsia  or  other  disturbances  of  nutrition  appear  they  must  be  treated, 
but  without  overlooking  the  necessary  prohibition  of  large  quantities  of 
cow  's  milk. 

In  addition  to,  or  in  combination  with  the  phosphorus  and  cod-liver 
oil,  large  doses  of  calcium  salts  should  be  ordered.  The  calcium  lactate  or 
the  calcium  chloride,  ten  grams  (5iii),  to  200  c.c.  (Sviii),  of  water  may  be 
given  in  doses  of  one  tablespoonful,  five  times  a  day,  or  better  still,  according 
to  S.  F.  Meyer,  the  calcium  bromide,  twenty  grams  (5  vi),  to  300  c.c.  (5x),  of 
water  to  be  given  in  similar  doses. 

This  treatment  should  be  continued  throughout  convalescence  from  the 
various  forms  of  tetany.  It  may  be  added  that,  at  times,  raw  milk  given,  of 
course,  under  the  most  careful  precautions,  is  preferable  to  sterilized  milk. 

Laryngospasm  and  eclampsia,  however,  require  much  more  strenuous 
measures.  The  invariable  rule  may  be  laid  down  that  the  child  who  is  suf- 
fering from  these  dangerous  symptoms  should  be  given  a  cathartic  imme- 
diately. A  teaspoonful  of  castor  oil  may  be  repeated  several  times.  If 
meteorism  exists,  lavage  of  the  bowel  should  be  given  at  once,  and  again 
in  two  hours  if  indicated.  Milk  should  be  discontinued  at  the  same  time. 
Only  boiled  water,  sweetened  if  necessary,  should  be  given  for  twenty-four 
hours.  Salt  solutions  are  contraindicated.  If  mother's  milk  is  obtainable 
the  day  is  won;  otherwise  it  is  well  to  give  rice  or  oatmeal  gruels,  to  which 
thirty  or  forty  grams  (^i-iss),  of  dextrin  and  maltose  a  day  may  be  added. 
This  diet  is  to  be  continued  for  several  days.  Phosphorus  and  cod-liver  oil, 
in  combination  with  calcium  salts,  should  be  given  from  the  beginning. 
After  this  initial  period  cow's  milk  may  be  added  gradually  and  carefully 
watched,  commencing  with  only  50  c.c.  (5i),  each  day  and  increasing  it 
slowly  if  the  symptoms  do  not  reappear.  Frequently  a  transition  to  malt- 
soup  feeding  is  to  be  recommended.  Weeks  may  elapse  before  increases  of 
weight  are  observed. 

In  atrophic  infants,  especially  if  the  atrophy  is  due  to  flour-feeding 
injury,  the  feeding  method  requires  grave  consideration.  Not  infrequently 
it  fails  to  influence  the  manifestations  of  spasmophilia.  If  no  wet-nurse 
can  be  procured,  one  may  have  to  be  content  with  giving  phosphorus 
and  cod-liver  oil  and  treating  the  disturbance  of  nutrition  according  to  the 
usual  methods.  It  is  apparent  that  the  persistent  forms  of  tetany,  as  a  rule, 
do  not  yield  very  readily  to  dietetic  influences.  Doubtless  protein-milk  will 
be  found  especially  useful  in  this  connection.  Finkelstein  recommends  that 
large  quantities  of  fluid  be  given  by  enteroclysis  and  that  moist  packs  be 
employed  for  their  sedative  influence. 


540  TEXT-BOOK  OF  PEDIATRICS 

Severe  eclamptic  attacks,  particularly  when  they  occur  in  rapid  suc- 
cession, require  special  treatment.  The  tepid  bath,  an  enema,  cooling  ap- 
plications to  the  forehead,  and  moist  packs  for  the  reduction  of  the 
high  fever  are  measures  which  can  be  employed  even  when  the  phy- 
sician is  not  at  hand.  If  the  convulsions  persist,  or  should  they  occur  very 
frequently,  chloral  hydrate,  to  be  given  per  rectum,  is  indicated.  To  infants, 
a  dose  of  0.5  gram  (grs.  viiss),  may  be  given  and  may  be  repeated,  if 
necessary,  in  a  short  time.  By  mouth  smaller  doses  should  be  given.  This 
remedy  may  be  employed  also  when  severe  and  threatening  laryngospasms 
occur.  Urethane,  in  one  or  two  gram  doses  (grs.  xv-xxx),  by  mouth,  or  in 
1.5-3.0  gram  doses  (grs.  xxv-xlv),  per  rectum,  is  also  useful.  Chloroform 
inhalations  as  a  means  of  relieving  the  status  eclampticus  are  to  be  con- 
sidered only  in  extreme  necessity.  It  is  possible,  at  times,  to  stop  re- 
peated convulsions  by  lumbar  puncture.  Several  good  results  have  been 
reported  in  the  spasms  attendant  upon  pertussis  (Eckert). 

Where  there  is  a  tendency  to  single  spasms,  and  especially  to  spasm  of 
the  glottis,  it  is  permissible  to  continue  for  a  few  days  the  internal  admin- 
istration of  sodium  bromide  or  calcium  bromide. 

1$  Sodii  bromidi,  grams  3.0  (Grs.  xlv). 

Aquse  destillatae,  c.c.  100  (Siii)- 
M.  Sig. — One  to  two  teaspoonfuls,  three  times  a  day. 

The  writer  has  had  but  little  experience  with  the  subcutaneous  injection 
of  magnesium  sulphate  so  highly  recommended  by  Berend.  The  solution 
is  prepared  by  adding  8.0  grams  (5ii),  of  magnesium  sulphate  to  100  c.c.  of 
water;  from  15  to  20  c.c.  being  used  for  the  injection,  which  may  be  re- 
peated, if  necessary,  on  the  following  day.  The  injection  is  painless  and  is 
said  to  affect  the  spasmophilic  symptoms  rapidly  and  favorably.  The 
presence  of  cystitis,  nephritis,  or  meningitis  are  contraindications  to  its 
use.  Special  dietetic  treatment  is  not  required,  but  the  avoidance  of  food 
containing  large  quantities  of  salt  is  essential.  Phosphorus  and  cod-liver  oil 
may  be  given  in  combination. 

In  closing,  a  few  suggestions  may  be  offered  for  the  treatment  of  severe 
laryngospasm.  Everything  that  may  frighten  or  excite  the  child,  such  as 
throat  inspection,  the  test  of  the  Trousseau  phenomenon,  and  even  the 
unnecessary  presence  of  persons  in  the  room,  should  be  carefully  avoided. 
The  child 's  head  should  rest  upon  a  horse-hair  pillow  or  upon  an  air 
cushion,  in  preference  to  a  feather  cushion.  A  vessel  of  cold  water  and  a  hypo- 
dermic syringe,  containing  camphor  in  oil,  should  be  kept  beside  the 
bed.  During  the  periods  of  most  frequent  attack  the  child  must  be  under 
direct  supervision  by  day  and  by  night.  At  the  onset  of  a  severe  attack,  the 
attendant  should  watch  quietly  at  first,  but  if  the  child  does  not  get  air 
after  a  very  short  time  some  cold  water  should  be  dashed  over  it.  If  the 
attack  still  continues  the  back  of  the  tongue  is  to  be  depressed  with  the 
finger  and,  if  necessary,  an  injection  of  camphor  in  oil  is  to  be  given. 
Attempts  should  be  made  to  practice  artificial  respiration.  The  effort  often 
meets  with  an  insuperable  obstacle  in  the  fact  that  the  spasm  firmly  closes. 


DISEASES  OF  THE  NERVOUS  SYSTEM  541 

the  opening  between  the  vocal  cords,  which  will  not  permit  the  passage  of 
air.  As  soon  as  the  child  begins  to  breath  of  its  own  accord,  the  well- 
known  crowing  sound  being  heard,  it  is  best  to  desist  from  any  attempt  at 
further  aid  in  order  to  avoid  exciting  a  new  convulsion.  If,  however,  the 
breathing  does  not  become  regular  artificial  respiration  should  be  con- 
tinued. Intubation  or  tracheotomy  never  can  be  done  in  time,  because 
death  is  due  to  stoppage  of  the  heart  and  not  to  asphyxiation.  The  prac- 
tice of  prior  and  continued  intubation  to  tide  the  child  over  days  of  greatest 
danger  may  be  considered. 

Finally,  it  may  not  be  superfluous  to  add,  that  comparatively  to  the 
frequency  of  laryngospasm,  deaths  arising  from  it  are  quite  rare.  It  is 
usually  possible  to  master  the  several  manifestations  of  spasmophilia. 

2.  ECLAMPSIA  DUE  To  NON-SPASMOPHILIC  CAUSES 

Not  all  eclamptic  attacks  occurring  in  infancy  or  among  older  children 
develop  upon  the  basis  of  a  spasmophilic  diathesis.  A  certain  proportion  of 
them  are  caused  by  organic  diseases  of  the  brain,  by  way  of  malformations, 
porencephalus,  intracranial  hemorrhage,  sclerosis,  lues  of  the  brain,  and 
hydrocephalus.  A  certain  number  are  due  to  meningitis.  Of  those  not 
traceable  to  organic  causes,  the  so-called  idiopathic  convulsions  of  early 
childhood,  a  majority  come  under  the  head  of  spasmophilia.  A  goodly 
percentage,  however,  ranging  from  7  to  20  per  cent,  of  all  eclampsias,  are 
nothing  less  than  true  epilepsy  of  infancy  which,  in  later  life,  develops  into 
the  typical  form.  It  is  also  true  that  certain  poisons  occasionally  cause 
convulsions  in  children.  Among  these  are  alcohol,  opium,  santonin,  mush- 
rooms and  other  vegetable  poisons.  To  complete  the  etiologic  tale,  it  must 
be  noted  that  convulsions  are  a  phenomenon  of  uremia.  Urinalysis  and 
the  presence  of  edema  ma,}'  suggest  this  origin  in  individual  cases. 

There  remains  a  considerable  number  of  convulsive  disorders,  the  na- 
ture of  which  is  not  yet  known.  A  part  of  these  are  of  reflex  quality  and 
some  appear  to  be  the  result  of  intestinal  auto-intoxication.  Presumably 
many  a  grave  eclamptic  picture  depends  upon  serous  meningitis,  of  the 
relations  of  which  but  little  has  been  known  until  recently.  It  seems  to  be 
true,  also,  that  in  children  beyond  the  period  of  infancy,  \vho  show  a  certain 
neuropathic  tendency,  convulsive  attacks  are  occasionally  caused  by  ex- 
trinsic influences,  such  as  infectious  diseases,  disorders  of  digestion,  and 
notably  profound  psychical  disturbance.  The  psychasthenic  convulsions 
of  Oppenheim,  the  nervous  convulsions  of  Bendix  and  the  functional  epi- 
leptic convulsions  of  Bratz  are  in  this  category.  These  functional  epilep- 
tic convulsions,  however,  do  not  occur,  as  might  be  imagined,  in  direct 
consequence  of  psychic  traumata,  but  these  traumata,  rather,  are  followed 
by  days  or  weeks  of  nervousness,  during  which  period  the  convulsions 
may  develop.  A  favorable  prognosis  distinguishes  these  conditions  from 
true  epilepsy. 

The  so-called  terminal  convulsions  seen  in  extremely  cachectic  infants, 
after  rapid  losses  of  weight  and  particularly  of  water,  in  pylorospasm,  or  in 
the  course  of  chronic  disturbances  of  nutrition  and  always  in  the  stage  of 


542 


TEXT-BOOK  OF  PEDIATRICS 


extreme  exhaustion,  have  nothing  to  do  with  spasmophilia.  Most  prob- 
ably they  are  to  be  regarded  as  the  results  of  the  action  of  bacterial  poi- 
sons, or  of  poisons  developed  in  the  intermediate  metabolism  of  the  child, 
or  of  serious  molecular  changes  incident,  in  part  at  least,  to  the  loss  of 
water  in  the  nerve  cells  (Thiemich). 

The  differential  diagnosis  of  these  several  forms  of  convulsions  is  often 
very  difficult.  The  attacks  may  be  identical  in  character.  The  demon- 
stration of  mechanical  and  electrical  hyper-irritability  shows,  in  most  in- 
stances, that  the  eclampsia  is  of  tetanoid  origin.  It  should  be  remembered 
however,  that  the  spasmophilic  child  may  be  affected,  like  any  other,  with 
meningitis,  encephalitis,  etc.  Emphasis  must  be  laid  upon  the  fact  that 
spasmophilic  convulsions  are  almost  unknown  before  the  third  month;  that 


Flo.  141. — Unilateral  convulsion  in  a  four-day-old  child  with  porencephaly. 

individual  attacks  are  usually  of  short  duration,  and  that  the  child  hardly 
ever  makes  any  outcry  during  the  attack.  In  the  recognition  of  meningitis, 
the  tensity  of  the  fontanelle  and  the  general  hyperesthesia  are  particularly 
important  points.  Idiopathic  convulsions  cause  a  bulging  of  the  fontanelle 
only  during  the  attack  unless,  indeed,  one  convulsion  follows  another  with- 
out intermission. 

Lumbar  puncture  is  to  be  urgently  advocated  in  all  doubtful  cases. 
Convulsions  occurring  during  the  first  three  months,  and  particularly 
during  the  first  few  weeks  of  life,  are  commonly  due  to  organic  brain  lesions, 
and  most  frequently  to  meningeal  hemorrhage  resulting  from  difficult  la- 
bor. Cases  have  been  seen,  however,  in  which  the  convulsions  were  as- 
sociated with  nutritional  disturbances  and  disappeared  speedity  when  the 
diet  was  regulated. 

Paralyses  or  pareses  remaining  after  a  seizure,  even  though  they  are 


DISEASES  OF  THE  NERVOUS  SYSTEM  543 

transient,  testify  to  the  organic  cause  of  the  convulsions.  A  unilateral 
type  of  convulsions,  on  the  other  hand,  is  quite  often  seen  in  purely  func- 
tional eclampsia.  Cases  to  which  a  parental  history  of  epilepsy  attaches 
always  arouse  the  suspicion  of  that  disease.  This  is  true,  also,  of  those 
instances  in  which  single  or  group  attacks  occur  at  longer  or  shorter  inter- 
vals without  provocative  causes.  Such  children  may  be  naturally  fed;  they 
give  no  evidence  of  febrile  disease  or  of  nutritive  disturbances;  and  the 
electrical  reactions  of  their  peripheral  nerves  are  constantly  normal.  It 
must  not  be  forgotten  that  an  interval  of  several  years  may  fall  between 
these  first  convulsions  of  infancy  and  the  later  manifestations  of  epilepsy. 
In  older  children,  in  whom  convulsions  develop  with  accompanying  high 
fever,  it  is  well  to  remember  that  one  may  have  to  deal  with  the  onset  of  an 
infectious  disease. 

Treatment. — The  symptomatic  treatment  above  described  may  be 
found  equally  useful  in  most  of  the  non-spasmophilic  convulsions.  Thor- 
ough evacuation  of  the  bowels  is  almost  always  indicated,  together  with 
hydrotherapeutic  antipyresis.  In  the  terminal  convulsions  of  digestive 
or  nutritional  disease  in  infancy,  neither  cathartics  nor  chloral  hydrate 
should  be  used.  In  these  cases  the  subcutaneous  infusion  of  a  physiologic 
saline  solution  or  its  use  by  enteroclysis  is  indicated.  For  the  rest,  treat- 
ment must  depend  upon  the  making  of  an  accurate  diagnosis,  since  menin- 
gitis, brain  syphilis,  early  hydrocephalus,  exogenous  poisoning,  uremia, 
etc.,  will  each  suggest  its  particular  therapeutic  indications.  Incision  of 
the  gums,  circumcision,  and  other  similar  resources  of  perplexity  cannot 
be  countenanced. 

GENERAL  MUSCULAR  HYPERTONIA,  WITHOUT  SPASMOPHILIA 

Briefly,  attention  should  be  called  to  the  fact  that  frequently  infants  who  are  not 
sphasmophilic  and  do  not  evidence  organic  brain  lesions,  exhibit  continuous  muscular 
spasms,  especially  of  the  lower  extremities.  These  are  definitely  related  to  acute  or 
chronic  disturbances  of  nutrition  and  are  particularly  common  in  children  who  have 
been  injured  by  excessive  flour  feeding.  They  persist  for  weeks,  or  even  months,  with 
but  slight  variations  of  intensity,  until  they  disappear  gradually  with  a  general  im- 
provement of  nutrition.  These  hypertonias  quite  commonly  affect  the  muscles  of  the 
back  and  neck  to  the  point  of  developing  a  well-nigh  constant  opisthotonos  which, 
combined  with  other  spasms,  simulates  the  picture  of  cerebral  disease.  It  does  not 
show  any  exaggeration  of  the  reflexes.  In  the  early  months  of  infancy  such  spasms, 
constituting  the  myatonia  of  Hochsinger,  are  observed  in  the  course  of  such  serious 
general  disease  as  sepsis  or  congenital  syphilis,  or  following  such~"ssvere  injuries  as 
extensive  burns. 

3.    NUTANT    AND    ROTATORY    SPASMS 

This  rather  uncommon  disorder  consists  in  the  development  of  turning, 
twisting  and,  more  rarely,  of  nodding  movements  of  the  head  which  the 
affected  child  exhibits  upon  lying  down.  While  very  evidently  the  move- 
ments are  involuntary,  the  child  remains  entirely  conscious.  The  disease  is 
seen,  at  the  earliest,  in  the  fourth  month  and  disappears  after  the  third 
year.  It  is  usually  continuous  for  weeks  or  months,  varying  in  its  intensity 
from  time  to  time.  Upon  close  observation  it  will  be  noted  that  the  peculiar 


544  TEXT-BOOK  OF  PEDIATRICS 

short,  but  fairly  rapid  movements  of  the  head  are  increased  whenever  the 
•eyes  are  fixed  upon  any  object,  and  are  usually  accompanied  by  a  distinct 
nystagmus.  This  symptom  is  noticed,  however,  at  other  times.  It  is  ex- 
aggerated if  the  head  be  held  still  and  may  appear  independently  of  the  head 
movements.  All  manifestations  of  the  disease  cease  during  sleep.  The 
nutant  spasm  appears  chiefly  in  rickitic  children.  A  neuropathic  taint 
may  play  some  part  in  its  development.  Its  exciting  cause  seems  to  be 
found  in  the  relative  darkness,  or  the  poor  lighting  of  the  room  in  which  the 
child  is  housed  (Raudnitz),  necessitating  the  turning  of  the  eyes  upward 
and  sidewise  when  the  child  seeks  to  look  at  the  light. 

Diagnosis. — Nystagmus  due  to  amblyopia,  with  clouding  of  the  cornea, 
etc.,  must  be  excluded.  The  twisting  of  the  back  of  the  head  in  rickitic 
children  who  suffer  with  hyperhydrosis,  eczema,  etc.,  may  be  readily 
recognized  as  a  voluntary  thing.  Complex  movements  resembling  nutant 


FIG.  142. — Pseudotetanus. 

spasm  are  not  uncommon  in  idiocy.     The  so-called  stereotypies  may  be 
cause  for  confusion. 

Treatment. — Placing  the  child  in  well-lighted  rooms,  the  improvement 
of  its  general  health,  and  the  treatment  of  existing  rickets  usually  result  in 
the  disappearance  of  this  form  of  spasm. 

4.  PSEUDOTETANUS 

Pseudotetanus  (Escherich)  is  a  rare  disease,  occasionally  seen  in 
infancy  but  generally  in  children  from  four  to  six  years  of  age.  The  clinical 
picture  commonly  develops,  in  full,  without  fever.  It  simulates  traumatic 
tetanus  in  all  particulars,  excepting  that  no  wound  is  present  and  no  tetanic 
bacilli  are  demonstrable.  Taking  an  ascending  path  from  the  legs,  a  tetanic 
rigidity  of  all  the  muscles  of  the  trunk,  back,  neck,  and  face,  with  resulting 
trismus  or  lockjaw  (Fig.  142)  gradually  develops.  Only  the  hands  and 
arms  and  the  ocular  muscles  remain  free.  As  in  true  tetanus,  excitement, 
noise,  etc.,  call  forth  convulsive  paroxysms.  During  sleep  the  rigidity  re- 
laxes, but  does  not  entirely  disappear.  The  characteristic  signs  of  spasmo- 
philia  are  lacking. 

Complete  recovery  usually  occurs  in  the  course  of  several  weeks.  The 
nature  of  the  disease  is  unexplained.  It  may  have  some  relation  to  true 
tetanus  (Pfaundler) .  The  treatment  is  symptomatic.  Chloral  and  bromides 


DISEASES  OF  THE  NERVOUS  SYSTEM  545 

and,  if  necessary,  morphin,  with  feeding  by  stomach  tube  are  indicated. 
Whenever  true  tetanus  is  even  suspected  the  specific  serum  treatment 
should  not  be  neglected. 

5.  EPILEPSY 

Epilepsy  is  a  very  common  disease  of  childhood.  Nevertheless  it  will 
be  but  briefly  discussed,  since  in  a  general  way  it  presents  practically  the 
same  manifestation?  as  in  the  adult. 

Symptomatic  and  typical  forms  of  the  disease  are  recognized.  The  first 
of  these  is  etiologically  related  to  organic  lesions  of  the  brain,  involving 
inflammatory  and  degenerative  processes  and  resulting  in  scars,  cysts, 
etc.  It  may  be  due  to  traumata  and  is  often  a  consequence  of  the  cerebral 
palsy  of  children  (q.  v.).  In  this  section  only  the  true  form  of  epilepsy  will 
be  discussed. 

True  epilepsy  is  a  disease  in  the  etiology  of  which  hereditary  factors  play 
an  important  part.  Among  these,  parental  epilepsy,  alcoholism,  neuro- 
pathies, nervous  diseases  of  various  forms,  and  congenital  lues  are  numbered. 
Its  well-known  but  variant  manifestations  will  be  briefly  described.  Three 
principal  types  are  recognized;  the  major  epilepsy  or  grand  mal',  the  minor 
epilepsy  or  petit  mal;  and  the  psychic  equivalents.  Certain  paralytic 
equivalents,  by  way  of  paroxysmal  and  at  times  painful  paralyses  of  definite 
parts  of  the  body,  without  spastic  symptoms  and  without  loss  of  conscious- 
ness, are  also  distinguished. 

Attacks  of  grand  mal  occur  in  childhood  as  they  do  in  adult  life.  An 
aura,  not  always  constant,  is  succeeded  by  sudden  pallor,  falling,  and  loss 
of  consciousness.  In  rapid  succession  follow  a  stage  of  tonic  general  spasms, 
associated  with  cyanosis,  and  a  stage  of  clonic  convulsions  in  which  the 
tongue  is  bitten  and  other  injuries  may  be  sustained.  In  this  phase, 
foaming  at  the  mouth,  fixation  of  the  pupils,  evacuation  of  urine  and  feces, 
etc.,  occur.  Finally  the  patient  falls  asleep  and  upon  awakening  is  com- 
pletely amnesic  (see  Figures  143-144).  Any  characteristic  aura  and  the 
initial  outcry  noticed  in  adults  are  often  wanting  in  children. 

The  minor  and  simpler  attacks  of  petit  mal  are  more  frequent  in  child- 
hood than  in  later  years.  They  are  manifested  by  sudden  and  very  brief 
fainting  spells,  by  attacks  of  dizziness,  or  by  so-called  absences.  The  child 
pales  for  a  moment,  the  expression  grows  blank  and  distant,  the  sentence 
or  the  play  is  interrupted,  and  any  object  in  the  patient's  hand  is  dropped. 
Then  it  all  passes  and  the  child  resumes  his  play,  as  though  nothing  had 
happened,  or  occasionally  he  falls  asleep.  In  other  instances,  rudimentary 
manifestations  of  motor  irritation  appear;  a  few  lightning-like  twitchings, 
sometimes  recurring  in  an  identical  muscle  group,  are  observed. 

Still  another  epileptic  manifestation  which  may  be  seen  in  children  is  the 
salaam  spasm  or  nodding  epilepsy,  a  succession  of  rapidly  repeated  bowings 
of  the  head  or  body,  as  if  in  greeting.  In  this  form  consciousness  is  not 
necessarily  lost,  but  amnesia  may  follow.  Yet  another  type  is  the  epilepsia 
cursiva  marked  by  a  sudden  run  forward,  which  terminates  either  in  a 
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fall  or  an  encounter  with  some  obstacle,  when  unconsciousness  or  a  convulsive 
attack  ensues. 

The  psychic  equivalents  of  the  epileptic  state  do  not  play  so  important  a 


FIG.  143. — Epileptic  attack.    Beginning  of  the  clonic  stage. 


Fia.  144. — Epileptic  attack.    Last  stage.     Foaming  at  the  mouth,  sleep. 

role  in  childhood  as  in  adult  life,  in  that  they  rarely  tend  to  the  com- 
mission of  criminal  acts.  Still  they  are  not  entirely  unknown  among 
children  and  manifest  themselves  in  fits  of  unreasonable  ill-temper  or 
excitement,  marked  by  disobedience,  stubbornness,  senseless  demands  upon 


DISEASES  OF  THE  NERVOUS  SYSTEM  547 

their  companions,  and  the  exhibition  of  intense  anger.  The  more  character- 
istic type  of  dream-like  abstraction,  associated  with  apparently  well-con- 
sidered action,  with  the  desire  to  roam  and  to  force  the  way  into  strange 
places,  etc.,  have  been  observed.  Subsequent  amnesia  is  not  absolutely 
essential  to  this  type. 

The  number,  frequency  and  periodicity  of  the  seizures  differ  in  each 
case.  The  status  epilepticus,  leading  to  continuous  attacks,  which  may 
seriously  threaten  life  is  not  of  unusual  occurrence  even  in  childhood.  The 
beginnings  of  epilepsy  in  children  have  been  carefully  studied  by  Birk. 
Three  forms  of  onset  may  be  distinguished. 

1.  Epilepsy  taking  an  intermittent  course.    One  attack  or  a  succession 
of  seizures,  occurring  in  infancy  and  often  failing  of  correct  diagnosis,  is 
followed  by  a  long  interval  of  freedom,  after  which  attacks  of  grand  mal  or 
petit  mal  develop.    The  period  of  the  reappearance  of  the  disease  is  com- 
monly that  of  school  age  or  of  puberty.     In  the  interim,  the  child  often 
presents  symptoms  of  nervous  disturbance,  alterations  of  voice,  irritability, 
pavor  nocturnus,  fits  of  anger,  and  often  diminished  intelligence. 

2.  An  uninterrupted  course  of  epilepsy  persisting  from  earliest  child- 
hood.   This  form  is  the  most  common  one,  although  the  disease  usually 
takes  on  a  more  moderate  degree  for  a  certain  time  after  the  initial  attacks 
in  infancy.    In  this  intermediate  period,  in  fact,  the  seizures  are  sometimes 
so  mild  as  to  escape  recognition  and,  if  observed,  their  true  interpretation 
awaits  the  reappearance  of  the  grand  mal. 

3.  Forms  of  epilepsy  which  appear  in  later  childhood.    In  these  types, 
again  the  favorite  period  of  onset  is  either  at  school  age  or  at  puberty. 

Course  and  Termination. — 'Very  few  epileptics  escape  some  measure  of 
mental  impairment.  Generally  speaking,  a  gradual  change  of  character  and 
a  progressive  mental  decay,  which  varies  from  the  mildest  degree  of  defect 
up  to  complete  idiocy,  sets  in.  Easily  angered,  irritable,  not  infrequently 
given  to  acts  of  violence,  temperamentally  brutal,  these  children,  even 
though  their  mental  faculties  are  fairly  well  preserved,  present  difficult 
problems  in  training  with  respect  to  their  familial,  social  and  communal 
relations.  As  a  rule,  the  psychic  deterioration  is  in  direct  proportion  to  the 
number  of  attacks  the  child  suffers,  so  that  the  frequent  recurrence  even  of 
petit  mal  must  be  considered  serious.  Recoveries  or  improvements  so 
great  as  to  approach  very  closely  to  recovery  are  uncommon,  but  are  not 
unknown.  The  prognosis  is  always  more  favorable  if  the  child  is  treated 
early  and  if  the  initial  attacks  appear  late. 

Diagnosis. — Attacks  of  grand  mal  may  be  confused  with  other  types  of 
convulsions.  Its  differentiation  from  infantile  eclampsia  has  been  previously 
discussed  (page  542) .  Late  eclampsias  may  be  distinguished  by  their  history 
and  by  the  discovery  of  the  pathognomonic  signs  of  spasmophilia,  a  not 
unimportant  distinction  to  make  because  of  the  favorable  prognosis  which, 
under  suitable  treatment  with  phosphorus  and  cod-liver  oil,  the  latter  affords. 
The  symmetrical  defects  of  the  enamel  of  the  teeth  as  a  symptom  of  tetanoid 
disturbances  of  metabolism,  in  early  childhood,  are  of  some  significance. 
The  hyperpyrexic,  reflex,  and  sporadic  convulsions  of  later  childhood  are 


548  TEXT-BOOK  OF  PEDIATRICS 

assignable,  in  part,  to  eclampsia  and,  in  part,  to  true  epilepsy,  but  probably 
relate  to  the  latter  as  a  type  of  metabolic  epilepsy  to  be  discussed  presently. 
Some  of  these  cases,  exhibiting  frequently  repeated  attacks  of  convulsions 
due  to  psychic  trauma  ("affekt-epilepsie"),  in  children  of  emotional 
quality  and  suggestive  of  a  neuropathic  type,  must  be  distinguished  from 
true  epilepsy  because  of  their  much  more  favorable  prognosis.  Nodding 
spasms,  Maladie  des  Tics,  simple  fainting,  may  be  readily  excluded  by 
careful  observation.  A  differentiation  from  hysteria  may  be  very  difficult 
both  in  the  major  and  in  the  minor  form.  At  times  it  even  happens  that 
hysteria  may  be  associated  with  epilepsy.  Severe  injuries,  scars,  teeth 
marks  in  the  tongue,  foaming  at  the  mouth,  absence  of  the  pupillary  reflex, 
are  pathognomonic  signs  of  an  epileptic  attack.  The  readiness  with  which 
they  are  excited,  the  retention  of  consciousness,  the  success  of  treatment  by 
cold  water  and  by  psychic  influence,  are  indications  of  hysteria.  No  diag- 
nostic dependence  can  be  placed  upon  the  presence  or  absence  of  amnesia. 
Success  or  failure  in  diminishing  the  severity  of  the  disease  by  a  change  of 
scene  is  not  conclusive  evidence  for  or  against  hysteria,  since  like  indeter- 
minate results  have  been  frequently  observed  in  epilepsy.  Other  psychic  or 
physical  signs  usually  permit  a  differentiation  even  when  the  physician 
does  not  see  the  attacks  himself.  We  may  generally  hold  fast  to  the  fact 
that  deterioration  of  the  mental  faculties  by  repeated  epileptic  attacks 
is  typical,  and  where  this  is  not  clear,  room  may  be  left  for  a  more  favor- 
able prognosis. 

It  should  be  noted  that  some  children  suffer  slight,  repetitional  lapses  of 
consciousness  which  cannot  be  laid  at  the  door  of  either  epilepsy  or  hysteria. 
They  are  sometimes  called  narcolepsy  and  deserve  mention  on  account  of 
their  relatively  favorable  prognosis. 

Children,  between  four  and  eight  years,  are  often  affected  with  occa- 
sional "absences"  of  brief  duration,  without  actual  loss  of  consciousness. 
These  may  appear  from  ten  to  forty  times  a  day  for  years,without  interfering 
with  the  patient's  development.  They  do  not  respond  to  treatment  with  the 
bromides,  but  they  do  react  to  psychic  stimulation.  Mental  influences  may 
play  some  part  in  the  causation  of  the  disorder.  Long  continued  rest  in 
bed,  or  a  change  to  country  life  may  temporarily  arrest  its  course.  Since 
its  relationship  to  spasmophilia  has  been  shown,  it  may  be  expected  that 
spontaneous  recovery  in  individual  cases  will  be  hastened  by  dietetic  treat- 
ment, together  with  the  use  of  phosphorus  and  cod-liver  oil. 

Treatment. — First  of  all  it  is  to  be  said  that  certain  cases  of  epilepsy,  and 
not  of  the  symptomatic  type  alone,  may  be  cured  or  benefited  by  operative 
interference.  For  further  light  on  this  subject,  the  reader  is  referred  to  text- 
books of  neurology. 

The  correction  of  anomalies  of  refraction  is  not  to  be  overlooked,  since 
it  may  do  much  to  diminish  the  frequency  of  attacks.  A  positive  Wassermann 
reaction  demands  energetic  antiluetic  treatment.  A  number  of  cases 
of  metabolic  epilepsy  show  a  certain  dependence  upon  disturbances  of 
nutrition,  especially  in  the  field  of  digestive  function.  The  careful  study  and 
suitable  management  of  these  conditions  may  reduce  materially  the  number 


DISEASES  OF  THE  NERVOUS  SYSTEM  549 

of  seizures.  These  dietetic  corrections  should  include  the  avoidance  of  food 
rich  in  purins  and  in  sodium  chloride,  and  the  adoption  of  a  non-irritating 
and  largely  salt-free  vegetable  diet.  Not  only  the  abandonment  of  gross 
dietetic  errors  is  implied,  but  the  treatment  also  of  gastric  disorders  and 
particularly  of  hyperacidity,  and  the  relief  of  obstipation.  Complete  ab- 
stinence from  the  use  of  alcohol  is  essential. 

Medicinally  the  bromides  are  the  sovereign  remedy.  The  sodium 
bromide  alone,  or  in  combination  with  the  ammonium  salt,  is  to  be  pre- 
ferred. Enough  of  the  drug  should  be  given  to  arrest,  if  possible,  the  attacks. 
For  very  young  children  the  total  daily  dose  may  run  as  high  as  six  grams 
(ninety  grains).  Older  children  may  receive  as  much  as  eight  grams  (two 
drams).  Under  such  dosage,  the  clinician  must  be  prepared,  of  course,  for 
the  appearance  of  signs  of  bromidism.  The  quantity  may  be  decreased  after 
a  while  without  diminishing  the  results,  but  its  administration  in  adequate 
doses  must  be  continued  not  only  for  many  weeks,  but  in  some  cases  for 
years.  Usually  through  such  long  courses  of  treatment,  the  doses  of  the 
bromide  may  be  greatly  and  gradually  reduced.  Smaller  doses  of  bromine 
are  commonly  satisfactory  if  the  patient  is  kept  on  a  salt-free  diet  after 
the  method  of  Toulouse-Richet.  This  is  a  rather  difficult  form  of  treat- 
ment for  long  continuance  and  is  dangerous  in  a  degree,  so  that  it  is  best 
employed  periodically  or  when  rapid  and  intense  action  is  required.  Excel- 
lent results  are  reported  in  some  cases  with  the  use  of  pheno-barbital 
(luminal)  which  may  be  given  in  doses  of  three  to  five  grains  three  times 
daily.  Thyroidin  has  proved  of  occasional  benefit.  Combinations  of  the 
bromides  with  opium,  according  to  Flechsig,  have  been  used  successfully 
in  several  cases  when  bromine  alone  was  ineffective. 

In  the  treatment  of  the  epileptic  attack  itself  we  are  limited  to  the 
appropriate  protection  of  the  patient  against  injury.  The  sleep  following 
the  attack  should  not  be  disturbed.  The  status  epilepticus  may  be  com- 
bated by  an  enema  of  chloral  hydrate,  containing  0.5  to  2.0  grams  (8-30  grs.) 
or  with  amyl  hydrate,  in  solution  of  3  to  4  grams  (45-60  grs.),  to  100  c.c., 
(3  ounces),  of  warm  water  to  which  is  added  five  to  eight  drops  of  tincture  of 
strophanthus  or  opium  if  necessary.  According  to  Vogt,  a  high  enema  is 
effective  during  or  immediately  after  a  severe  seizure.  In  mild  cases  attend- 
ance at  school,  and  preferably  at  a  special  school,  is  possible  and  advisable. 
At  a  more  advanced  period  it  may  become  necessary  to  place  the  patient  in  a 
private  sanatorium  or  in  a  public  institution  devoted  to  the  care  of  epilep- 
tics. In  the  choice  of  occupation  only  light  tasks  about  the  house  or  garden 
should  be  considered. 

II.  CHOREA  MINOR    (ST.  Virus  DANCE) 

Chorea  minor  is  a  neurosis  of  subacute  course,  probably  of  infectious 
nature,  chiefly  observed  in  childhood,  and  marked  by  choreic  disturbances 
of  motion  and  associated  psychic  changes. 

The  motor  disturbances  in  chorea  consist  of  a  series  of  lightning-like 
contractions  of  individual  muscles  combined  with  certain  peculiar  forms  of 


550 


TEXT-BOOK  OF  PEDIATRICS 


incoordination  (Foerster).  The  faults  of  coordination  are  seen  in  the  hesi- 
tation over  voluntary  acts  and  their  complication  with  involuntary  move- 
ments; in  the  failure  to  maintain  attempted  positions;  in  the  lack  of  that 
cooperative  work  of  accessory  muscles  and  of  the  opposing  muscular  groups 
upon  which  the  development  of  equilibrial  motor  complexes  depends.  The 
impulses  to  spontaneous  movement  excite  the  marked  contractions  of 
widely  separated  muscles,  which  become  annoyingly  prominent  in  every 
act  and  occasion  a  constant  restlessness  of  the  entire  body. 

The  fully  developed  clinical  picture  of  chorea  cannot  be  mistaken. 
The  child  is  in  constant  action,  now  jerking  the  shoulder,  now  hoisting  the 
arm  in  a  peculiar  manner,  now  again  throwing  the  head  to  one  or  the  other 

side.  The  face  is  in  continual  mus- 
cular play;  the  most  variable  expres- 
sions appear  in  kaleidoscopic  array; 
at  one  moment  brimming  with  merri- 
ment, the  next  changing  to  embarrass- 
ment, restlessness,  fright,  or  modesty. 
The  muscles  of  the  face,  shoulders 
and  hands  are  always  affected  most 
severely;  but,  in  many  cases,  those  of 
the  trunk  and  the  legs  also  participate 
in  the  muscular  unrest.  In  the  latter 
event,  the  gait  is  very  much  disturbed 
and  standing  and  sitting  may  become 
impossible.  The  patient  falls  help- 
lessly when  placed  upon  his  feet.  In 
these  severe  cases  all  voluntary  action 
is  thwarted.  Such  a  child  is  unable 
to  dress  or  undress  or  to  feed  himself. 
Speech  is  similarly  disordered  and 
often  fails  entirely;  the  little  sufferer, 
with  much  grimace,  whispering  and 
stuttering  but  a  few  words.  Very 
gradual  is  the  approach  to  this  fully 
developed  phase  of  the  disease.  At  the  onset,  the  motor  disturbances  are 
less  marked  and  may  even  be  interpreted  as  intentionally  erratic.  The 
affected  child  is  often  punished  at  school  for  his  inability  to  write,  and  at 
home  when  he  drops  objects  on  every  occasion.  His  school  companions 
quickly  notice  the  muscle  twitchings  and,  mocking  and  imitating  them, 
tend  to  induce  their  rapid  aggravation.  It  is  always  true  that  the  invol- 
untary movements  are  more  marked  when  attention  is  directed  to  them 
and  the  child  attempts  to  control  them.  This  motor  restlessness  sub- 
sides in  sleep,  except  in  the  rare  form  of  chorea  nocturna  in  which  it  may 
be  even  more  intense  during  the  night. 

Physical  changes  in  chorea  minor  are  usually  discernible  from  the  very 
beginning  of  the  disease.  They  are  evidenced  by  irritability,  peevishness, 


FIG.  145. — Chorea  minor.  Seven  and  one-half- 
year-old  girl.  Told  to  sit  quiet,  involuntary 
motions  of  the  muscles  of  the  face  and  neck,  and 
the  right  arm  and  leg. 


DISEASES  OF  THE  NERVOUS  SYSTEM  551 

sudden  fright  and  failure  of  mental  concentration.  Serious  psychoses 
hardly  ever  develop  in  children. 

In  addition  to  the  characteristic  symptoms  described,  a  flaccidity  of  the 
limbs  or  hypotonia  is  usually  demonstrable  (Bonhoeffer),  in  fully  developed 
cases.  It  is  usually  recognized,  in  lifting  the  child,  by  the  familiar  discovery 
of  the  definite  looseness  of  the  shoulder.  •Commonly  the  reflexes  are  not 
decreased.  Gordon  has  called  attention  to  a  quite  peculiar  reaction  of  the 
patellar  reflex,  determined  in  a  certain  number  of  cases.  The  lower  leg, 
thrust  forward  by  the  reflex,  is  fixed  for  a  moment  in  this  position  and  sinks 
back  slowly  to  the  point  of  rest.  Muscular  power  is  affected  only  in  excep- 
tional instances  and  sensation  is  always  intact.  Pupillary  variations,  such 
as  inequality,  abnormal  dilation,  and  hippus  are  seen  occasionally.  Fever 
does  not  belong  to  the  clinical  picture,  but  may  develop  with  a  complicat- 
ing rheumatism. 

Cardiac  phenomena  appear  in  almost  every  case.  These  may  consist 
only  in  irregularities  of  the  pulse  or  arythmia;  but  very  frequently  sighing  or 
blowing  murmurs  are  heard.  They  may  wholly  disappear,  with  recovery 
from  the  chorea,  or  may  remain  permanently  present.  These  heart  mur- 
murs must  be  regarded  as  evidences  of  a  verruciform  endocarditis,  which 
may  lead  to  permanent  cardiac  lesions.  Pericarditis  is  much  less  common. 

Duration,  Course  and  Termination. — As  a  rule,  chorea  shows  a  fairly  rapid 
development  of  the  disease  to  its  full  height;  and,  after  a  variably  long  per- 
sistence, a  gradual  subsidence  to  its  final  disappearance  within  three  or  four 
months.  Cases  continuing,  however,  six  to  twelve  months  are  observed. 
Exacerbations  are  not  unusual  and  recrudescence  of  the  disease  is  quite 
common.  Recovery  is  the  rule,  but  fatal  results  have  been  reported  in  2 
or  3  per  cent,  of  the  cases.  In  these  fatalities  we  generally  trace  the  results 
of  a  septic  endocarditis,  or  unexpectedly  sometimes,  hyperpyrexia  and  coma 
develop  in  connection  with  a  complicating  serous  meningitis. 

Uncommon  Cases. — Hemichorea  is  unusual.  As  its  name  suggests, 
its  symptoms  are  confined  to  one  side  of  the  body. 

Chorea  mollis,  or  paralytic  chorea,  runs  a  course  marked  by  pareses  and 
muscular  weakness.  Its  motor  disturbances  may  play  a  very  secondary 
part,  but  a  flaccid  monoplegia  or  paraplegia  and  a  loss  of  reflexes  ensue, 
which  may  be  correctly  interpreted  only  by  the  antecedence  of  the  choreic 
movements  or  by  the  subsequent  return  of  motor  power.  The  prognosis 
in  these  pareses  is  favorable. 

Etiology. — Age  and  sex  play  a  causative  part.  The  disease  is  very 
uncommon  before  the  fourth  year  and  is  probably  seen  most  frequently 
between  the  seventh  and  the  twelfth  year.  Girls  are  peculiarly  predisposed. 
Neuropathic  stigmata  must  be  counted  among  the  favoring  factors.  Psychic 
trauma,  sudden  fright,  etc.,  may  excite  chorea.  Syphilis  but  rarely  enters 
into  consideration  as  an  etiologic  factor. 

A  relationship  to  articular  rheumatism  in  its  several  forms  is  so  fre- 
quently demonstrated  in  choreics  that  there  is  growing  tendency  to  regard 
chorea  as  a  form  of  rheumatic  disease,  coordinal  with  the  joint  inflam- 


552  TEXT-BOOK  OF  PEDIATRICS 

mations  and  with  endocarditis.    In  this  sense  we  have  come  to  speak  of  an 
infectious  chorea  despite  its  afebrile  course. 

In  actual  experience  not  only  is  an  endocarditis  often  seen  in  the  course 
of  chorea,  but  the  heart  disease  may  antedate  the  appearance  of  the  chorea 
as  a  consequence  of  a  rheumatic  attack,  or  an  articular  rheumatism  may 
supervene  and,  at  times,  alternate  with  exacerbations  of  chorea.  Indeed, 
the  development  of  an  acute  chorea  has  been  seen  during  a  recovery  from  an 
attack  of  articular  rheumatism.  The  rarer  complications  also  of  articular 
rheumatism,  such  as  erythema  nodosum  or  multiforme,  have  been  observed 
in  connection  with  chorea. 

Pathogenesis. — No  definite  infective  organism  is  yet  known.  The 
disease  is  generally  supposed  to  be  due  to  toxic  or  infective  injuries  of  large 
brain  areas.  According  to  Bonhoeffer,  a  disease  of  the  cerebellar  peduncles 
and  of  the  cerebellum  itself  may  be  held  responsible  for  the  choreic  disturb- 
ances of  motion. 

Diagnosis. — Simple  irregular  movements,  due  to  embarrassment,  are 
frequently  seen  in  young  children,  which  may  suggest  the  picture  of  an 
early  chorea.  A  flaccidity  of  the  limbs  and  the  progressive  course  of  the 
disease  indicate  chorea.  Diadococinesis,  or  the  impossibility  of  rapidly 
alternated  pronation  and  supination  of  the  hand,  is  usually  observed  even 
in  the  early  stages  of  chorea.  It  is  quite  valuable  as  a  diagnostic  measure  in 
older  children.  It  is  important  to  note  that  a  symptomatic  chorea  is  ob- 
served in  certain  brain  affections,  such  as  cerebral  infantile  palsy.  Partic- 
ularly in  the  event  of  a  hemichorea  care  must  be  taken,  by  testing  the 
reflexes,  etc.,  to  exclude  organic  brain  disease.  Congenital  chorea  or  choreic 
symptoms  which  develop  during  the  first  year  of  life  are  always  so  asso- 
ciated. Tuberculous  meningitis  sometimes  begins  with  hemichorea. 

Chorea  electrica  will  be  discussed  later.  Hysterical  chorea  usually  ap- 
pears as  an  imitative  disease  and  may  spread,  epidemic-like,  through  a 
school  as  a  result  of  the  admission  of  a  case  of  true  chorea.  Superficially, 
it  presents  a  closely  similar  picture.  Close  examination  and  due  consider- 
ation of  the  attendant  circumstances  will  point  to  a  correct  diagnosis.  In 
such  cases  the  presence  or  absence  of  the  peculiar  type  of  patellar  reflex, 
already  described,  is  of  probable  diagnostic  value. 

Treatment. — The  most  important  factor  in  the  treatment  of  chorea  is 
rest.  The  child  should  be  kept  out  of  school  and  placed  in  a  suitable  environ- 
ment. The  members  of  the  immediate  family  may  not  exercise  a  desirable 
influence  over  him  and  it  may  become  necessary  to  remove  him  to  entirely 
new  surroundings.  Absolute  rest  in  bed  is  urgently  recommended  until 
the  severer  symptoms  have  disappeared.  The  disease  may  affect  the  general 
nutrition  of  the  child  and  care  must  be  taken  that  he  receives  sufficient 
nourishment.  Sometimes  this  is  far  from  an  easy  matter  on  account  of  the 
interference  with  the  act  of  deglutition  and  the  consequent  necessity  of 
careful  feeding.  Cold  water  treatments  are  harmful;  while  protracted  tepid 
baths,  and  especially  long-continued  moist  packs  over  the  entire  body 
surface,  often  have  a  very  favorable  effect.  A  combination  of  change  of 


DISEASES  OF  THE  NERVOUS  SYSTEM  553 

scene,  of  rest  in  bed,  and  of  such  methods  of  bathing  may  make  all  other 
treatment  unnecessary. 

Medicinally,  nothing  is  to  be  expected  from  the  salicylates  and  other 
antirheumatic  remedies.  Antipyrin  seems  to  be  more  useful.  The  disease 
is  possibly  shortened  by  a  course  of  treatment  with  arsenic.  The  dose 
should  be  gradually  increased  in  the  usual  manner.  It  must  not  be  carried 
too  far  if  good  results  are  to  be  expected.  From  six  to  eight  drops  of  the 
Fowler's  solution,  three  times  a  day,  should  be  the  maximal  limit.  Injec- 
tions of  sodium  cacodylate  may  also  be  employed.  Salvarsan,  or  neosal- 
varsan,  given  intravenously  or  intramuscularly,  has  acted  favorably  in 
several  refractory  cases. 

In  severe  forms  of  the  disease,  chloral  hydrate  may  be  necessary  to 
secure  for  the  patient  the  necessary  sleep.  If  the  heart  is  affected,  amylene 
hydrate,  in  doses  of  3.0  grams  (45  grs.),  per  rectum,  or  bromide  may  be 
preferred.  Thiemich  recommends  the  trial  of  scopolamin  hydrobromide,  in 
doses  of  one-half  to  one  milligram  (Mo~Mo  grain),  once  a  day. 


PARAMYOCLONUS  MULTIPLEX;  CHOREA  ELECTRICA 

Paramyoclonus  is  characterized  by  symmetrical  convulsive  contractions  of  single 
muscles  or  groups  of  muscles,  those  of  the  shoulder  girdle,  the  arms  and  the  face  being 
chiefly  involved.  They  may  be  very  frequent  and  do  not  respond  to  treatment. 
Psychic  trauma^nd  hereditary  neuropathies  play  an  important  part  in  their  etiology. 

Chorea  electrica  is  a  collective  term  covering  various  convulsive  diseases  which  are 
not  proper  to  chorea  minor.  Some  of  these  cases  are  probably  related  to  paramyoclonus; 
others,  perhaps,  to  Maladie  des  Tics,  to  epilepsy  or  to  hysteria.  These  latter  types 
show  a  marked  tractability  under  proper  suggestive  treatment.  In  the  epidemics  of 
so-called  chorea  electrica,  observed  by  Dubini  in  upper  Italy,  in  which  a  large  mortality 
was  noted,  there  was  undoubtedly  a  form  of  organic  central  or  meningeal  disease. 

III.  NEUROPATHIC  AND  PSYCHOPATHIC  CONSTITUTION 

(HEREDITARY  NEUROPATHY) 

The  neuropathic  or  psychopathic  constitution  plays  a  large  role  in 
childhood.  Its  full  significance  has  been  realized  but  recently.  Under  these 
terms  are  grouped  those  abnormal  hereditary  tendencies  of  the  nervous 
system  which  tend  to  develop  in  the  direction  of  a  number  of  nervous  or 
psychic  disturbances.  Primarily,  these  abnormal  tendencies  manifest 
themselves  in  reactions  to  physical,  mental,  or  psycho-emotional  stimuli, 
which  in  their  intensity,  duration  and  effect  put  the  personal  life  of  their 
subjects  into  sharp  and  distinct  contrast  with  that  of  normal  individuals. 
Such  neuropathic  or  psychopathic  children  can  hardly  be  considered  as 
mentally  deficient.  In  fact,  the  greater  impressionability  of  their  nerv- 
ous system  not  infrequently  gives  them  an  intellectual,  artistic,  or  es- 
thetic quality  of  rather  unusual  order.  In  them,  indeed,  we  have  to  deal 
with  developmental  conditions,  the  correct  appreciation  and  proper  peda- 
gogic training  of  which  may  be  of  the  highest  importance  in  the  evolution 
of  character. 

The  explanation  of  the  condition  is  to  be  found  in  two  chief  factors,  not 
infrequently  cooperative.  The  first  of  these  is  the  inheritance  of  certain 


554  TEXT-BOOK  OF  PEDIATRICS 

stigmata  which  may  be  traced  back  to  generations  of  varied  nervous  and 
mental  disease  in  the  family  of  one  or  both  of  the  parents.  Neurasthenia 
and  hysteria  in  the  immediate  ancestry  are  of  essential  significance. 

The  second  factor  is  seen  in  the  injurious  influence  of  a  mentally  un- 
healthy environment  in  which  the  child  is  reared  and  from  which  he  re- 
ceives his  first  impressions  and  experiences  in  the  relation  of  his  ego  to  the 
world  at  large.  These  injurious  influences  are  apt  to  be  exaggerated  in  the 
case  of  an  only  child  of  the  family. 

Other  extrinsic  conditions,  in  the  burdens  of  school  life,  the  awakening  of 
the  sexual  powers,  the  effects  of  traumata  or  of  infectious  diseases  and  the 
like,  have  a  secondary  but  an  important  influence  in  such  lives.  They  do 
not,  as  a  rule,  affect  the  normal  child,  but  in  the  nervously  or  psychically 
abnormal  they  often  excite  the  most  variable  afflictions  which  must  come 
up  for  later  discussion.  Among  the  far-reaching  exogenous  injuries  from 
which  such  young  nervous  subjects  suffer  is  that  of  the  habitual  use  of 
alcohol.  It  should  be  said  that  an  exudative  diathesis  is  often  combined  with 
the  symptoms  of  neuropathy. 

Symptoms. — The  clinical  pictures  which  the  neuropathic  constitution 
presents  are  as  varied  as  life  itself.  In  early  infancy  such  children  are 
usually  distinguished  by  their  abnormal  tendency  to  fright  and  by  the 
fitfulness  of  their  sleep.  As  their  intellectual  faculties  develop,  various 
psychic  peculiarities  appear,  conditioned  upon  the  type  of  their  hereditary 
stigmata  and  the  influence  of  their  particular  environment.  They  are 
chiefly  manifest  in  their  emotional  qualities.  Extreme  and  intense  excita- 
bility, outbursts  of  violent  temper  or  emotion,  not  due  to  any  physical  con- 
dition, may  make  their  appearance  even  in  late  infancy.  The  child  soon 
holds  the  entire  family  under  his  tyrannic  sway  and  does  not  yield  the 
sceptre  it  holds  without  a  struggle.  He  compels  the  mother  to  sit  beside 
his  bed  until  he  falls  asleep,  or  keeps  her  rocking  him  half  the  night.  He  will 
eat  only  certain  foods  and  accepts  them  only  from  certain  dishes.  The 
most  ordinary  tasks  of  every-day  life  are  subject  to  his  expressed  desires. 
Parent  or  would-be  teacher  is  punished  for  every  supposed  slight  to  the 
small  egotistical  personality  by  hours  of  pouting  and  sullenness,  by  the 
obstinate  refusal  of  food,  or  even  by  actual  attack,  or  by  an  outburst  of 
anger  in  which  the  child  rolls  about  on  the  floor  and  acts  as  though  insane. 

In  another  type,  an  abnormal  timidity  appears  to  govern  the  entire 
nature  of  the  child.  He  is  afraid  to  be  alone  or  to  stay  in  the  dark,  afraid  of 
even  harmless  domestic  animals,  etc.  Or,  again,  he  exhibits  an  extreme 
variability  of  temperament.  The  most  insignificant  occurrence  throws  the 
child  out  of  his  customary  routine  and  changes  his  happy  demeanor  to  one 
of  sadness.  Unlike  the  grief  of  the  heathy  child,  this  is  not  of  momentary 
duration  and  easily  consoled.  The  mood  persists  for  hours,  perhaps,  or 
even  days  and  is  maintained  against  all  consciously  pleasant  impressions. 
Still  another  type  of  child  is  extremely  prone  to  complain;  exquisitely  hypo- 
chondriacal  thoughts  employ  his  waking  moments  or  he  constantly  over- 
flows with  sickly  sentimentality.  Yet,  again,  the  child  develops  into  a 
precocious  wiseacre  in  whom  every  trace  of  childish  innocence  is  soon  lost. 


DISEASES  OF  THE  NERVOUS  SYSTEM  555 

In  brief,  it  is  not  hard  to  see  in  the  individual  case  the  mirrored  picture  of 
its  environment  or  the  product  of  an  inherent  tendency,  fostered  by  its 
surroundings,  in  the  easily  influenced  character  of  the  child. 

Elaborations  of  idiosyncrasy  are  encountered  in  the  imaginative  realm 
which  are  described  as  pathologic  dreaming.  The  active  phantasy  of  the 
child  not  only  translates  him  into  the  successive  roles  that  his  play-dreams 
make  for  him,  but  it  becomes  difficult  for  him  to  distinguish  between  imag- 
ination and  reality.  Upon  this  phantasiastic  tendency  the  child  constructs 
long  stories  as  though  they  were  tales  of  actual  experience,  all  the  inci- 
dents of  which  may  be  shown  later  to  be  of  pure  invention  (pseudologia 
phantastica) .  Not  infrequently  these  tales  are  found  to  serve  the  momen- 
tary advantage  of  the  child.  Lying  accusations  of  adults  by  such  children 
are  not  uncommon  and  the  stories  they  may  tell  of  sexual  attack  are 
often  "made  of  whole  cloth." 

As  physiologic  stigmata,  unusual  activity  and  fidgeting  are  observed  in 
many  cases.  These  peculiarities  may  be  noted  during  the  first  year. 
There  is  often  times  a  markedly  labile  quality  of  the  vasomotor  mechan- 
ism, which  manifests  itself  in  rapid  changes  of  color  in  the  face,  in  easy 
variations  of  the  pulse-rate,  and  in  dermatographia.  The  deep  reflexes 
are  often  increased,  while  the  conjunctival  and  swallowing  reflexes,  on  the 
contrary,  may  be  diminished.  Not  uncommonly  the  facialis  phenomenon 
is  encountered  in  children  of  school  age  who  show  no  other  signs  of  the 
spasmophilic  diathesis.  Intercurrent  affections  of  the  skin  and  the  air 
passages  cause  an  abnormal  degree  of  irritation  and  coughing  in  such  chil- 
dren (Czerny).  The  so-called  stigmata  of  degeneration,  such  as  cranial 
and  facial  asymmetry,  malformations  of  the  ears  or  the  genitalia,  cryp- 
torchidism,  strabismus,  left-handedness,  etc.,  are  to  be  interpreted  as  in  the 
adult.  They  are  worthy  of  note,  especially  when  several  of  them  are 
present,  but  they  have  no  pathognomonic  significance. 

Peculiarities  of  habit  are  common.  Such  children  suck  their  thumbs  or 
their  lips,  bite  their  finger-nails,  pick  the  nose,  pluck  at  the  hair,  or  shake 
the  head  incessantly.  Such  constantly  repeated  motions,  which  may  be 
continued  even  in  sleep,  ihejactatis  capitis  nocturna  or  the  bowing  spasm  of 
the  trunk,  etc.,  are  called  stereo typies. 


The  more  moderate  disturbances  of  physical  and  psychical  equilibrium, 
so  far  discussed,  may  be  kept  within  due  bounds  or  speedily  improved  or 
even  cured  by  suitable  training  and  by  the  hygienic  influence  of  a  whole- 
some environment.  Tact  and  persistence,  the  very  qualities  apt  to  be 
wanting  in  the  home  of  such  a  child,  are  of,  course,  indispensable.  Sub- 
mission to  the  will  of  his  elders,  truthfulness,  habits  of  cleanliness,  the  sup- 
pression of  unfit  desires — all  of  these  essential  qualities  are  best  acquired 
from  the  example  of  the  teacher.  The  neuropathic  child  will  never  acquire 
them  in  the  constant  presence  of  the  living  example  of  their  opposites. 
Intercourse  with  normal  children  is  greatly  to  be  desired  and  is  often  the 
most  direct  remedy  for  egotism  and  timidity.  The  school  is  a  preparation  for 
the  future  life  of  the  child  and  is  greatly  to  be  preferred  to  individual  tutor- 


556  TEXT -BOOK  OF  PEDIATRICS 

ing  at  home.  When  the  tendency  to  indulgence  in  phantasy  and  pathologic 
dreams  is  especially  marked,  the  mind  must  be  directed  to  real  values  by 
practical  occupations  around  the  house  or  in  the  garden.  Modelling,  manual 
training,  the  collection  of  natural  objects  and  the  observation  of  nature,  are 
means  to  this  end.  The  pleasure  of  production  inherent  in  every  child  must 
be  aroused.  Fairy  stories,  tales  of  horror,  and  lessons  unadapted  to  its 
age,  may  injure  the  child  materially.  It  is  important  that  such  children 
should  be  sent  to  bed  at  a  suitable  hour  with  unalterable  regularity.  Sexual 
impressions  should  be  guarded  against.  To  allow  the  child  to  sleep  with 
adults,  to  witness  the  careless  personal  exposure  which  some  parents  permit 
themselves,  or  the  exercise  of  their  more  intimate  relations,  is  to  incite  a 
probably  serious  disturbance  of  his  psychic  balance. 

All  of  these  measures  and  precautions,  but  superficially  touched  upon, 
are  of  greater  importance  than  disciplinary  attempts  which,  as  a  rule,  ac- 
complish little  when  the  training  has  once  been  started  in  the  wrong  di- 
rection. Likewise,  they  are  far  more  important  than  the  prescription  of 
"nerve-building  foods,"  or  of  hydrotherapeutic  methods  which  have  proved 
absolutely  useless  arid  suffice  only  to  promote  the  acquirement  of  a  full- 
fledged  hypochondriasis. 

To  these  milder  manifestations  of  the  neuropathic  constitution  may  be 
added  symptoms  which  have  a  distinct  pathologic  quality  and  which  period- 
ically overshadow  the  general  status  and  seriously  affect  the  life  of  the 
child.  Certain  symptom-complexes  commonly  attach  to  the  conception  of 
neurasthenia  and  still  others  to  that  of  hysteria.  Apart  from  these  quite  a 
number  of  isolated  expressions  of  disease,  such  as  migraine,  tic  malady, 
etc.,  may  appear.  The  true  psychoses  may  develop  upon  this  constitutional 
basis,  but  they  are  uncommon  in  childhood.  Some  epilepsies,  a  large  per- 
centage of  cases  of  enuresis,  and  certain  disorders  of  speech  may  also  relate 
themselves  to  the  neuropathic  group. 

The  psychopathic  constitution,  in  so  far  as  it  may  be  congenitally  traced 
is  often  in  close  heredity  to  more  or  less  serious  degrees  of  f eeble-mindedness, 
a  fact  which  makes  the  prognosis  in  the  given  case  more  grave. 

1.  MIGRAINE;  HEMICRANIA 

Migraine  is  a  distinctly  hereditary  neurosis.  It  occurs  in  childhood,  but 
in  less  acute  form  than  in  later  years.  Its  periodic  attacks  of  severe  head- 
ache, associated  with  the  vomiting  of  bile,  resemble  those  of  the  adult  in 
every  other  respect,  making  any  special  discussion  of  the  disorder  superfluous. 

2.  MALADIE  DES  TICS  CONVULSIFS 

Under  this  term  we  group  certain  peculiar  convulsive  movements  of  the 
muscles  of  the  face,  especially  those -concerned  in  winking,  scowling,  grind- 
ing of  the  teeth,  etc.,  or  of  the  muscles  of  the  trunk,  neck  or  limbs,  producing 
such  acts  as  nodding,  jerking  of  the  shoulders,  grasping  with  the  hands, 
and  even  dancing  and  jumping.  These  movements  monotonously  repeated 
and  without  variation,  are  distinguished  from  the  stereotypies  by  their 
convulsive  character.  As  a  rule,  they  increase  very  markedly  when  the 


DISEASES  OF  THE  NERVOUS  SYSTEM  557 

patient  believes  himself  under  observation  or  when  he  becomes  excited. 
The  movements  are  to  a  certain  extent  controllable  by  the  will.  In  connec- 
tion with  them  some  children  utter  a  cough  or  bark  or  even  indecent  words. 

There  are  cases,  mistaken  for  tic,  which  are,  in  reality,  manifestations  of 
hysteria,  as,  for  instance,  the  saltatory  reflex  spasm  and  other  similarly  com- 
plex motions,  which  are  readily  amenable  to  treatment.  In  other  cases, 
these  convulsive  contractions  are  associated  with  voluntary  or  primarily 
intentional  movements;  they  are  quite  analogous  to  the  stereotypies  in  their 
mode  of  origin,  but  are  not  infrequently  curable.  The  best  success  is  gen- 
erally attained  by  properly  individualized  gymnastic  treatment.  The 
patient  being  placed  before  a  mirror,  the  attempt  is  made  to  keep  the  affected 
muscles  absolutely  at  rest  by  will  control  alone,  while  the  abnormal  inner- 
vation  of  these  muscles  is  suppressed  by  means  of  slow,  irregular,  voluntary 
movements.  These  exercises  must  be  carefully  supervised  and  directed  by 
the  physician. 

3.  EMOTIONAL  RESPIRATORY  CONVULSIONS;  ABSENCES 

Under  this  caption  are  included  convulsive  respiratory  pauses, 
occurring  during  emotional  excitement  and  particularly  in  exhibitions  of 
anger.  Consequently  they  are  sometimes  called  convulsive  rage.  They 
simulate  very  closely  the  true  laryngeal  and  respiratory  convulsions  of 
spasmophilia.  They  do  not  produce,  however,  a  true  laryngospasm.  Res- 
piration, as  a  rule,  stops  in  the  midst  of  a  crying-fit  and  following 
either  a  deep  unobstructed  inspiration  or  a  profound  expiration.  In  the 
course  of  the  ciying,  the  child  suddenly  rolls  its  eyes,  grows  rigid  and 
cyanotic,  throws  himself  about,  and  finally  falls  unconscious.  Usually 
he  recovers  completely  within  a  few  seconds.  The  signs  of  the  spasmo- 
philic  diathesis,  a  heightened  electrical  excitability,  the  Trousseau  phe- 
nomenon, etc.,  are  wanting. 

These  convulsions  occur  chiefly  during  the  run-about-age,  from  two  to 
five  years,  although  they  are  met  with  in  infancy.  In  some  instances  the 
child,  doubtless,  is  volitionally  concerned,  to  a  degree,  in  the  initiation  of 
these  attacks;  learning  to  incite  them  when,  in  the  face  of  parental  opposi- 
tion, he  desires  to  get  his  own  way.  When,  however,  the  mechanism  of  the 
attack  is  once  set  in  motion,  it  passes  beyond  the  patient 's  control.  The 
spasms  may  appear  spontaneously  as  a  result  of  fear  or  other  psychic 
excitement.  In  some  cases  this  condition  is  preceded  in  infancy  by  a  true 
spasmophilic  laryngospasm. 

Prognosis. — -The  prognosis  is  supposed  to  be  entirely  favorable.  When 
one  has  seen  some  very  severe  cases,  however,  he  will  accept  this  view 
cautiously,  although  no  fatal  outcome  has  been  reported. 

Treatment. — The  treatment  should  be  essentially  prophylactic,  but  not 
to  the  point  of  giving  way,  as  is  too  often  done,  to  the  child 's  every  whim 
and  fancy.  The  child  should  be  given,  rather,  to  understand  that  he  must 
expect  severe  punishment  if  he  holds  his  breath.  It  is  often  possible  to 
avert  an  attack  by  threat  or  blow  or  by  the  sudden  distraction  of  some 
unexpected  occurrence. 


558  TEXT-BOOK  OF  PEDIATRICS 

The  more  anxious  and  disturbed  is  the  attendant,  the  more  readily  do 
the  "absences"  occur.  On  this  account  a  change  of  environment  or  even  a 
short  stay  in  hospital  may  prove  as  desirable  in  severe  cases  of  this  sort  as 
it  is  in  other  forms  of  neuropathic  disturbance,  where  the  object  is  to 
eliminate  the  element  of  sympathy. 

A  combination  of  the  bromides  with  a  course  in  psychotherapy  is  to  be 
recommended.  In  the  presence  of  the  attack  itself  the  treatment  appro- 
priate to  true  laryngospasm  is  indicated.  Cold  water  should  be  dashed 
in  the  patient 's  face  and,  if  necessary,  artificial  respiration  is  to  be  employed. 

PATHOLOGIC  REFLEXES 

The  emotional  respiratory  spasms  are  actually  the  prototype  of  a  number  of  nervous 
disturbances  which  may  be  regarded  as  pathologic  phases  of  the  normal  reflexes.  They 
are  usually  classed  as  monosymptomatic  hysteria.  They  involve  the  reflex  perpetu- 
ation of  abnormal  motor  phenomena  which  originally  had  been  caused  by  local 
pathologic  conditions.  After  the  disappearance  of  the  original  pathologic  stimulus  they 
persist,  in  a  degree,  as  a  functional  habit,  responsive  to  physiologic  stimuli  of  ordinary 
character,  but  in  the  exaggerated  degree  which  depends  upon  the  emotional  quality  of 
the  subject.  Thus  habitual  winking  or  spasm  of  the  eyelids  may  persist  after  conjunc- 
tivitis; polyuria  may  continue  after  irritation  of  the  bladder;  nervous  cough  after 
laryngitis  or  bronchitis.  Seemingly  typical  attacks  of  whooping-cough  may  occur  for 
weeks  or  months  after  recovery  from  true  pertussis  or  may  be  reproduced  by  a  slight 
bronchitis,  etc.  Some  forms  of  infantile  vomiting,  rumination,  etc.,  are  to  be  better 
understood,  perhaps  in  the  same  light. 

Therapeutically  it  is  possible  sometimes  to  break  up  the  abnormal  symptom-complex 
by  the  introduction  of  some  new  and  unusual  f actor  -in  the  reflex  event.  Thus,  in 
rumination  or  habitual  vomiting,  the  feeding  of  gruel  often  serves  a  good  purpose. 
With  older  children,  suggestive  treatment,  together  with  use  of  the  faradic  current  is 
often  useful  in  particular  with  nervous  cough,  polyuria,  and  the  like.  It  maybe  neces- 
sary to  confine  oneself  to  the  treatment  of  the  general  nervous  condition  of  these  patients. 

4.  PAVOR  NOCTURNUS 

This  very  common  malady  consists  in  a  sudden  awakening  from  sleep 
in  a  state  of  fear.  Generally,  it  occurs  but  once  in  the  course  of  a  night,  but 
it  may  be  frequently  repeated  at  irregular  intervals.  Children  suffering 
with  this  abnormal  condition  are  usually  between  four  and  eight  yeara  of 
age.  The  attack  occurs  during  the  early  sleeping  hours.  The  child  rouses 
suddenly  with  an  expression  of  deadly  fear  or  intense  fright;  screams, 
defends  himself  from  imaginary  objects,  clings  to  his  mother,  and  is  quieted 
only  by  lighting  the  room  and  reassuring  him  for  several  moments.  Half 
an  hour  may  elapse  before  the  child  drops  to  sleep  again.  His  confused 
speech  often  indicates  the  nature  of  the  alarming  dream  of  ghosts,  robbers, 
animals,  etc.,  he  has  experienced.  Often  it  seems  that  the  child  does  not 
really  emerge  from  its  dream  into  full  consciousness.  The  remainder  of  the 
night  passes  undisturbed  and  in  the  morning  the  child  remembers  neither 
the  dream  nor  the  physician  who  sat  by  his  bed. 

These  attacks,  often  described  as  nightmare,  may  be  traced  sometimes 
to  such  physical  causes  as  tight  clothing,  an  overloaded  stomach,  or  a  dis- 
tended bladder.  Intestinal  parasites  may  be  occasionally  responsible;  but 
the  cause  is  more  often  attributable  to  respiratory  obstructions,  chronic 


DISEASES  OF  THE  NERVOUS  SYSTEM  559 

coryza,  hypertrophy  of  the  tonsils,  and  adenoids.  The  treatment,  if  all 
these  points  are  taken  into  consideration,  will  not  infrequently  give  prompt 
results.  It  is  desirable,  however,  to  study  the  often  highly  developed  imag- 
inative quality  of  children  so  affected  and  to  prohibit  everything  by  which 
the  imagination  may  be  excited.  Fairy  tales  and  other  fantastic  stories, 
theatrical  performances,  moving  pictures,  the  influence  of  sexual  impres- 
sions, and  the  use  of  alcoholics,  should  be  avoided.  As  in  all  the  functional 
neuroses  of  .childhood,  the  element  of  fear  should  be  especially  considered. 
Sometimes  the  pavor  will  disappear  at  once  if  the  child  is  removed  from  the 
room  in  which  the  parent  or  the  nurse  sleeps. 

In  the  matter  of  the  differential  diagnosis,  it  must  not  be  forgotten  that 
true  epilepsy  may  hide  behind  an  apparent  pavor  nocturnus.  The  oc- 
currence of  irregular  exhibitions  of  enuresis  is  especially  important  in 
this  connection. 

5.  NEURASTHENIA 

Neurasthenia  is  characterized  by  rapidly  increasing  exhaustion  of 
pathologic  degree,  with  an  abnormal  irritability.  Neurasthenia  of  extrinsic 
origin,  the  nervous  collapse  which  comes  as  a  result  of  excessive  demands 
upon  physical  and  mental  energy,  the  acute  nervous  exhaustion,  is  very 
uncommon  in  childhood.  It  occurs,  probably,  only  in  those  who  attempt 
wage-earning  with  school  attendance,  even  at  the  expense  of  the  night 
hours.  The  neurasthenia  of  childhood  which  develops  upon  the  basis 
of  a  neuropathic  diathesis  is  quite  common  and  is  a  many-sided  thing.  The 
nervous  system  of  those  who,  whether  constitutionally  or  as  a  result  of 
improper  training,  are  unprepared  for  the  experiences  and  unfit  for  the 
ordinary  exertions  of  life,  proves  incapable  of  meeting  the  small  daily  tests 
and  demands  which  the  average  school  makes.  This  is  particularly  true 
when  the  readily  exhausted  child  is  spurred  on,  by  his  own  ambition  or  that 
of  his  parents — and  ambition  is  apt  to  be  boundless  in  the  neuropathic 
family — to  persistent  efforts  during  his  school  years  which  simply  serve  to 
destroy  the  capacity  of  his  nervous  system.  Repeated  disappointments, 
following  upon  strenuous  endeavor,  are  the  hardest  physical  blows  which 
such  a  child  has  to  sustain.  In  fact  some  of  the  suicides  of  children  are 
traceable  to  this  fact. 

The  more  aggravated  forms  of  masturbation,  so  commonly  observed,  are 
not  a  cause  of  neurasthenia  but  the  result  rather  of  psychopathic  stigmata. 
Nevertheless,  the  habit  may  contribute  measurably  to  the  increase  of 
neurasthenic  symptoms. 

The  objective  symptoms  of  neurasthenia  are  identical  with  those  of  the 
neuropathic  constitution.  To  repeat  them  in  brief:  increase  of  the  deep 
reflexes,  diminution  of  the  conjunctival  and  swallowing  reflexes,  rapidly 
alternating  pallor  and  flushing,  a  variable  pulse-rate,  dermatographia,  and 
the  facialis  phenomenon.  Added  to  these  are  often  noted  an  increase  of 
blood-pressure,  at  times  amounting  to  a  pulsating  rigidity  of  the  arterial 
walls ;  variations  in  the  vigor  of  the  nerve  supply  to  the  facial  muscles  and 
the  pupils ;  restless  movements ;  spasm  or  tremor  of  the  eyelids  when  closed 


560  TEXT-BOOK  OF  PEDIATRICS 

(Rosenbach's  phenomenon),  hyperhydroeis,  stuttering,  etc.  As  a  rule, 
varying  combinations  of  a  number  of  these  symptoms  appear.  A  slight 
degree  of  anemia,  may  be  coincident  and  is  often,  but  erroneously,  con- 
sidered causal  of  the  neurasthenia. 

Physically,  neurasthenia  may  lead  to  a  variety  of  complaints  which  can 
be  merely  mentioned.  The  most  important  of  these  are  headache  and  head 
pressure.  These  occur  chiefly  among  school  children  and  their  exciting 
causes  are  to  be  found  in  anemia  and  in  the  unhygienic  conditions  of  the 
schoolroom.  Headache  usually  increases  during  school  hours  and  may 
eventually  become  continuous,  so  as  to  be  present  even  on  rising.  It  may 
diminish  if  the  child  is  allowed  to  sleep  late  on  Sunday.  Anorexia, 
gastric  discomfort,  obstipation  and  vomiting,  the  latter  often  occurring 
on  the  way  to  school  or  after  forcing  down  an  unwelcome  breakfast,  are 
not  uncommon. 

Nervous  asthenopia  (Wilbrand  and  Sanger),  deserves  particular  men- 
tion. It  is  marked  by  the  sense  of  flickering  before  the  eyes,  by  the  escape  of 
tears,  by  headache  and  eyeache  upon  reading.  It  shows  no  organic  lesion. 
Acute  diseases  have  a  much  more  severe  course  in  neurasthenic  children 
than  in  others.  Pertussis  (Czerny),  and  bronchitis,  for  instance,  often  taken 
on  an  asthmatic  character.  It  has  already  been  noted  that  itching  and 
coughing  are  exaggerated  symptoms  in  these  patients. 

Disturbances  of  sleep  are  common  with  them.  It  is  not  unusual  to 
find  an  infant  who  lies  wide  awake  for  half  of  the  night.  Falling  asleep 
is  difficult  and  often  long  delayed.  In  the  morning  the  child  dislikes 
to  wake  up  and  leaves  his  bed  but  poorly  rested  and  refreshed.  Trouble- 
some dreams,  pavor  nocturnus,  tics,  and  even  true  somnambulism  may 
further  disturb  the  patient's  rest. 

In  the  psychical  sphere,  the  element  of  fear  and  the  tendency  to  hypo- 
chondria demand  particular  emphasis.  For  the  latter,  the  adults  imme- 
diately associated  with  the  child  are  commonly  responsible,  but  it  deserves 
special  consideration  because  it  is  often  accentuated  by  the  pernicious 
activity  of  the  physician. 

In  children  of  advanced  school  age,  mental  exhaustion,  resulting  in 
feeble  memory,  inattention  and  want  of  concentration  may  play  an  impor- 
tant part.  The  child  loses  all  zest  for  work;  an  indefinable  fear  of  every 
school-task  to  which  he  is  set  possesses  him;  failure  of  accomplishment 
causes  further  deficiency,  and  a  consequent  apathy  and  dulness  results 
which  strangles  all  endeavor.  Should  the  parents  attempt  to  relieve  the 
situation  by  providing  private  instruction  for  the  child,  making  still 
greater  demands  upon  his  already  flagging  energies,  the  result  is  a  further 
injury  to  his  nervous  system  rather  than  an  improvement  in  his  school  work. 
A  child  in  this  stage  of  exhaustion  not  infrequently  commits  moral  wrongs,  as 
lying,  stealing  and  even  offering  violence  to  the  parents,  acts  which  are 
wholly  at  variance  with  his  true  character.  In  the  differential  diagnosis  of 
these  conditions,  dementia  prsecox  or  hebephrenia,  to  the  primary  stages 
of  which  they  bear  some  resemblance,  requires  careful  consideration. 


DISEASES  OF  THE  NERVOUS  SYSTEM  561 

Treatment. — The  treatment  of  neurasthenia  in  children  must  combine 
psychical  and  physical  measures  in  a  suitable  manner.  Hydrotherapeutic 
procedures,  abundance  of  fresh  air,  moderate  and  healthy  play,  together 
with  the  remedy  of  the  existing  anemia,  are  the  best  means  to  be  employed. 
It  should  be  remembered  that  heroic  attempts  to  harden  the  child  by  cold 
water  bathing  often  do  harm  and  serve  to  increase  the  neurasthenic  symp- 
toms (Hecker).  In  severe  cases  a  period  of  complete  rest  is  essential  and 
removal  from  school  for  several  weeks  may  be  absolutely  necessary. 
Equally  essential  is  it  to  obtain  an  accurate  knowledge  of  the  home  environ- 
ment and  of  the  psychical  influences  bearing  upon  the  child.  Since  in  only 
exceptional  cases  may  the  child 's  whole  environment  be  changed,  an  individ- 
ual plan  of  treatment,  which  takes  account  of  all  the  factors  detcrminable 
and  which,  too  frequently,  must  content  itself  with  compromises,  must  be 
worked  out  in  each  case.  Institutional  treatment,  climatic  cures,  sea- 
baths,  etc.,  have  the  advantage  that  they  introduce  the  child  to  new 
surroundings  for  a  time,  at  least.  Suggestive  treatment  is  of  small  value  for 
the  relief  of  neurasthenia.  The  personality  of  the  physician  may  accomplish 
much,  provided  he  can  master  the  effects  of  gross  deficiencies  of  training. 
Thus  it  may  be  possible,  at  least,  to  eliminate  the  constant  discussion  of  the 
child 's  affliction  as  a  topic  of  conversation.  He  may  even  give  the  parents 
to  understand  that  the  subject  should  not  be  mentioned  in  the  presence  of 
the  patient.  Further,  they  should  be  impressed  with  the  fact  that  punish- 
ment aggravates  the  condition;  that  regularity  in  the  entire  routine  of  liv- 
ing, and  especially  of  meal  hours  and  bedtime,  must  be  rigidly  enforced; 
and  that  all  pathologic  ambitions  must  be  curbed. 

Special  attention  should  be  directed  to  the  diet.  Czerny  and  Siegert 
have  called  attention  to  the  fact  that  a  diet  consisting  largely  of  milk, 
meat  and  eggs  often  gives  the  nervous  disorder  a  strong  stimulus.  Protein 
is  to  be  minimized.  In  fact,  a  diet  consisting  largely  of  vegetables  and 
fruits,  without  eggs  and  with  but  little  milk,  is  most  appropriate.  The 
possible  use  of  alcohol  and,  by  older  patients,  of  tobacco  must  be  ascer- 
tained and  discontinued.  Masturbation  must  be  stopped.  Organic  dis- 
orders, such  as  oxyuris,  tend  to  increase  the  nervousness  and  should  be 
carefully  remedied. 

In  certain  cases,  the  use  of  bromides  may  be  unavoidable;  at  least 
temporarily,  in  order  to  combat  possible  sleeplessness  and  sexual  irritability 
alike.  As  little  as  possible  should  be  used.  Moist  packs  sometimes  serve 
the  same  purpose.  The  anorexia,  obstipation,  headache  and  mental  irrita- 
bility will  never  be  conquered  by  drugs  if  one  does  not  succeed  in  providing 
fresh  air,  and  light,  healthful  exercise  for  the  body,  with  rest,  self-reliance 
and  relief  from  all  excessive  demands  for  the  mind,  thus  bringing  the  ele- 
ments which  make  for  happiness  into  the  young  life. 

6.  PHOBIAS;  UNCONTROLLABLE  IDEAS  AND  ACTS 

Phobias,  or  conditions  of  fear  of  certain  places  or  persons,  of  articles 
of  clothing,  etc.,  are  comparatively  uncommon  in  childhood.    The  author 
has  had  the  opportunity  to  observe  one  young  child  who  has  suffered  for 
36 


562  TEXT-BOOK  OF  PEDIATRICS 

years  with  an  intense  fear  of  time-pieces  and  especially  of  clocks.  Much 
more  common  are  certain  uncontrollable  ideas  or  conceptions,  in  close 
relation  to  uncontrollable  acts.  They  offer  a  difficult  puzzle  when  the  child 
keeps  the  causative  motive  a  secret.  Several  examples  may  be  taken  from 
Strohmeyer  's  excellent  text.  For  instance,  one  child  habitually  thinks  of  a 
coffin;  another  is  haunted  by  the  idea  that  there  is  verdigris  on  its  fingers; 
and  still  another,  that  it  must  stab  its  mother,  or  that  it  has  committed 
some  sin.  A  child  is  sometimes  possessed  of  a  doubting  mania  and  must 
constantly  reassure  himself  that  he  has  carried  out  a  most  indifferent 
action  correctly. 

Exaggerated  pedantry,  excessive  scrupulousness,  compulsory  counting, 
and  the  like,  are  occasionally  observed  as  they  are  in  the  uncontrollable 
conception  neuroses  of  adults.  The  author  knows  of  a  case  in  which  every 
accidental  bump  or  touch  upon  one  side  of  the  body  caused  the  patient 
to  give  a  similar  bump  or  touch  to  the  symmetrical  point  on  the  other  side. 
If  he  did  not  succeed  in  directing  the  bump  to  the  identical  correspond- 
ing spot,  the  result  was  a  repeated  bumping  to  and  fro  in  the  attempt 
at  compensation. 

These  phobias,  or  uncontrollable  ideas,  are  not  always  of  serious  prog- 
nostic significance,  even  though  they  stand  very  near,  at  times,  to  the 
border-line  of  the  psychoses  or  may  even  be  regarded  as  within  the  pale.  It 
is  possible  that  suitable  pedagogic  training  and,  in  older  children,  a  con- 
scientious self-training  may  bring  about  a  recovery.  In  the  phobias  the 
possibility  of  a  sexual  relationship  must  always  be  considered. 

7.  DISTURBANCES  OF  PSYCHICAL  IMPULSES 

Poriomania. — The  habit  of  running  away,  or  poriomania  causes  children, 
and  particularly  boys,  to  leave  home  or  school  and  to  wander  about  without 
plan  or  aim.  They  may  be  found  far  from  home,  half-starved  and  exhausted. 
In  some  cases,  the  fear  of  punishment  seems  to  be  an  exciting  cause;  in  others 
a  deep  depression  rules  the  event,  which  cannot  be  traced  to  any  external 
factor  at  all.  Others,  again,  exhibit  an  uncontrollable  longing  for  the  open; 
while  occasionally  it  is  a  matter  of  hyperphantasy  and  again  of  mere  feeble- 
mindedness. It  is  always  important  to  decide  whether  the  basis  of  the  habit 
does  not  lie  in  an  epileptic  or  hysterical  subconsciousness.  In  the  treat- 
ment of  the  condition  a  long  continued  sojourn  in  a  suitable  institution  can 
hardry  be  avoided. 

Masturbation. — This  affliction  is  found  in  the  majority  of  weak-minded 
and  neuropathic  children  and  at  times  to  an  excessive  degree.  It  is  never 
the  cause,  but  always  the  result  of  the  neurosis,  whether  it  be  dependent 
upon  weakness  of  will  or  upon  an  excessive  and  premature  irritability  of  the 
sexual  apparatus.  It  is  more  fully  discussed  under  Diseases  of  the  Genito- 
urinary Organs. 

8.  HYSTERIA 

Hysteria  in  children  does  not  differ  in  its  nature  or  manifestations  from 
hysteria  in  the  adult.  Therefore  the  reader 's  attention  will  be  called  only  to 
the  few  peculiarities  it  presents  in  childhood. 


DISEASES  OF  THE  NERVOUS  SYSTEM  563 

Manifestations  of  hysteria  are  seen  very  often  in  children  and  may  be 
seen  the  more  often  if  the  physician  schools  himself  to  study,  not  only  the 
immediate  disease  that  he  is  called  upon  to  combat,  but  the  child,  sick  with 
the  disease,  as  an  entity.  The  frequency  of  the  condition  is  not  surprising 
when  one  considers  the  sensitiveness  of  the  childish  mind  to  suggestive 
impressions.  The  age  at  which  hysteria  is  first  observed  corresponds  with 
that  at  which  the  child  becomes  aware  of  his  surroundings  and  of  his  own 
personality,  which  is  between  the  second  and  third  year.  More  commonly, 
of  course,  the  disturbance  is  first  noted  at  school  age.  As  the  patient  grows 
older  it  approaches  more  and  more  closely  to  the  qualities  seen  in  the  adult. 
In  later  years,  girls  are  affected  a  little  more  frequently  than  boys.  Among 
causal  relations  we  very  often  find  a  distinct  taint  of  hereditary  neuropathy, 
while  injuries  of  environment  not  infrequently  have  a  potent  influence. 
The  directly  exciting  cause  may  be  of  an  apparently  physical  quality,  such 
as  a  blow,  a  fall,  etc.  In  all  probability  there  is  always  a  physical  trauma 
associated  with  the  psychical  injury.  Very  commonly  the  hysterical 
phenomena  follow  directly  upon  purely  psychical  traumata,  such  as  sudden 
fright,  fear,  domestic  grief,  etc.  Sometimes  the  condition  may  be  imposed 
upon  an  actual  organic  disease;  as,  for  instance,  when  abasia  develops  in 
connection  with  an  angina  that  has  confined  the  patient  to  bed;  or  an  hys- 
terical aphonia  remains  after  laryngitis;  or  paralysis  and  contractures 
follow  a  slight  contusion;  or  a  spasm  of  the  lids  persists  after  a  conjunctivitis 
has  subsided.  Some  of  the  phenomena  in  this  group  may  be  mistaken  for 
pathologic  reflexes  (see  page  558).  The  fixation  of  disease  symptoms  in  the 
subconscious  memory  of  such  children  is  readily  understood.  The  exces- 
sive anxiety  and  the  liberal  attention  lavished  upon  them  by  parents  and 
attendants,  in  the  event  of  illness,  offers  to  their  minds  distinct  advantages 
in  contrast  to  the  treatment  they  receive  when  they  a  re  well.  Indeed  there 
are  hysterical  mothers  to  whom  the  sick  child,  with  his  peculiar  sort  of 
suffering  and  with  the  general  interest  that  he  awakens,  appeals  more 
strongly  than  does  the  child  who  is  well  and  who  fairly  sun  themselves  in 
the  glory  reflected  from  the  poor  little  martyr  in  whose  service  they  are 
tied  hand  and  foot. 

By  way  of  example:  A  five-year-old  boy  was  brought  to  the  hos- 
pital suffering  with  abasia  and  a  peculiar  form  of  tonic  spasm,  resembling  in 
many  respects  a  pseudotetanus,  which  followed  upon  a  febrile  angina.  The 
manner  of  the  parents  suggested  a  suspicion  of  hysteria.  By  the  next  day  it 
was  already  possible,  with  the  aid  of  slight  faradization  and  the  suggestion 
that  the  boy  "march  like  a  soldier,"  to  get  him  on  his  feet;  the  following 
day  he  learned  to  climb  the  stairs,  and  then  rapidly  to  walk  and  turn  somer- 
saults— when  the  mother  promptly  removed  him  from  the  hospital,  very 
much  put  out  to  think  that  her  child  had  been  so  harshly  treated. 

With  the  usual  character  of  the  hysterical  child,  prone  to  deceit  and 
lying,  conscious  simulation  may  contribute  occasionally  to  the  development 
of  the  disease-picture.  Self-injuries  have  been  recorded  even  in  childhood. 

A  very  wide-awake  hysterical  boy  of  twelve  years  had  vomited  ascarides. 
Ever  since  this  event  he  had  from  time  to  time  produced  worms  which  he 


564  TEXT-BOOK  OF  PEDIATRICS 

claimed  had  crawled  out  of  his  mouth  or  nose.  His  parents  travelled  about 
with  him,  going  from  physician  to  physician,  spreading  his  fame,  and  always 
very  much  offended  if  anyone  ventured  to  doubt  the  alleged  facts.  With 
the  aid  of  an  apothecary  they  had  found  medieval  literature  in  which 
similar  cases  were  described.  The  boy  was  brought  to  the  hospital  where  he 
was  kept  under  careful  surveillance.  Nothing  happened  for  many  days, 
until  the  child  was  allowed  to  play  in  the  hospital  garden.  The  following 
day  he  appeared  and  triumphantly  produced  a  worm  which  had  come  out, 
he  said,  of  his  nose — but  it  happened  to  be  an  ordinary  angleworm. 

Not  infrequently  hysterical  manifestations  are  the  result  of  imitation. 
This  is  the  history  of  the  well-known  school  epidemics  of  chorea,  tremor  and 
similar  complexes,  starting  from  a  single  actual  case  in  the  small  community. 
The  patient  may  be  even  self-imitative,  so  that  an  attack  of  true  chorea 
may  recur  as  a  manifestation  of  hysteria. 

The  recognition  of  hysteria  in  children  may  be  a  very  difficult  matter  en 
account  of  the  monosymptomatic  type  of  the  disease.  The  generally  recog- 
nized stigmata  of  hysteria,  such  as  pressure  points,  anesthetic  zones,  limita- 
tion of  the  visual  field,  etc.,  are  frequently  absent  in  children  and  a  diagnosis 
must  be  made  rather  upon  the  strength  of  the  general  impression.  The 
child's  environment  must  be  considered  and  the  contrast  between  the 
objective  findings  and  the  subjective  symptoms  may  forecast  or  fully  deter- 
mine the  diagnosis.  Certain  forms  of  paralysis,  as  astasia  and  abasia,  in 
which  the  motility  of  all  the  limbs  and  even  of  all  the  muscles  is  intact, 
arouse  a  suspicion  of  hysteria.  Similarly,  cuff-like  circumscribed  bands  of 
anesthesia  or  analgesia,  which,  incidentally,  are  uncommon  in  childhood,  are 
scarcely  compatible  with  organic  disease  and  suggest,  at  once,  the  thought 
of  hysteria.  On  the  other  hand,  a  coxitis  or  a  contracture  of  the  elbow  may 
successfully  simulate  an  organic  condition. 

A  few  of  the  more  common  manifestations  may  be  cited.  Hysterical 
vomiting,  even  in  small  children,  may  make  the  question  of  adequate  feeding 
a  difficult  one  or  may  compel  the  parents  to  conform  the  dietary  to  the 
notions  of  the  small  tyrant.  Severe  scolding,  or  the  single  use  of  the  stomach- 
tube,  may  cure  such  cases  even  in  late  infancy.  In  older  children  a  persist- 
ent anorexia  and  hysterical  vomiting  may  affect  seriously  the  nutrition  of 
the  child.  It  is  not  always  easy  to  exclude  organic  disease  and  the  question 
is  very  often  determined  only  by  the  employment  of  strong  suggestions  or 
sharp  authority. 

Attacks  of  abdominal  pain,  meteorism,  pseudotumors,  tachypncea, 
bizarre  types  of  respiration,  stuttering,  asthma,  hiccough,  spasms  of  sneez- 
ing, pollakiuria,  diurnal  or  nocturnal  enuresis,  incontinence  of  the  bowels, 
may  all  appear  as  manifestations  of  hysteria .  Mutism ,  the  complete  inability 
to  utter  sounds,  in  which  no  attempt  to  speak  is  made,  an  inability  which  is 
sometimes  the  result  of  fright,  is  not  uncommon.  Hysterical  headache  may 
be  a  very  obstinate  symptom  and  is  hard  to  distinguish  from  the  neur- 
asthenic form. 

A  diagnosis  may 'be  possible  only  by  the  experience  of  the  prompt 
results  of  antihysteric  measures  and  by  the  sudden  disappearance  of  symp- 


DISEASES  OF  THE  NERVOUS  SYSTEM  565 

toms  when  the  patient's  attention  is  suddenly  distracted  by  some  pleas- 
ant impression. 

The  major  convulsions  of  hysteria,  with  their  well-known  quality  of 
clownism  and  their  pronounced  "attitudes  passionees, "  may  be  seen  in 
children  of  ten  years  or  even  less.  Generally  speaking,  they  are  of  uncom- 
mon occurrence,  but  having  once  occurred  they  will  be  easily  repeated 
during  consultation;  in  fact,  in  the  wards  they  may  be  provoked  by  sugges- 
tion. As  a  rule,  but  not  invariably,  they  may  be  readily  distinguished  from 
epileptic  seizures.  Their  differentiation  has  been  discussed  under  epilepsy. 
In  some  instances,  they  are  associated  with  fainting  spells  or  cataleptic 
attacks.  A  classical  case  of  so-called  chorea  magna  has  been  observed  in  a 
girl  less  than  six  years  of  age.  In  this  disorder  the  child  stages  a  complete 
performance  with  theatrical  precision,  tears  about  the  room,  shouts  in  con- 
fused speeches,  and  afterwards  remembers  nothing  of  the  event. 

As  additional  phenomena  of  hysteria  are  to  be  mentioned  hysterical 
insomnia;  paroxysms  of  fear,  which  subside  only  if  the  light  is  left  burning  in 
the  room  or  when  the  mother  or  nurse  remains  beside  the  bed;  somnambu- 
lism, daydreaming  or  diurnal  automatism  and  well-developed  twilight 
states.  Pseudologia  phantastica  (see  page  555),  often  blossoms  riotously  in 
hysterical  girls  and  not  infrequently  leads  to  false  accusations  of  attendants, 
against  which  even  the  physician  must  be  upon  his  guard. 

The  intelligence  of  hysterical  children  is  usually  good;  not  infrequently 
they  give  the  impression  of  precociousness  and  their  conversation  turns 
upon  subjects  better  suited  to  older  persons.  They  observe  their  elders 
closely,  even  while  their  interest  is  largely  or  wholly  centred  in  their  own 
personality.  The  desire  to  attract  attention  and  to  arouse  the  admiration 
of  others  is  always  in  the  foreground.  A  shrewd  hysterical  girl  in  the 
Heidelberger  Children's  Hospital,  thinking  she  was  not  receiving  sufficient 
attention  and  seeking  to  draw  observation  to  herself,  was  asked  the  motive 
of  her  acts  and  replied  uniquely  that  she  was  "luring  people. "  This  desire 
is  undoubtedly  the  main  spring  which  subconsciously  actuates  many  of  the 
described  symptoms  and  even  inspires  deeds,  otherwise  inexplicable,  which 
seem  to  be  the  fruit  of  an  evil,  ugly,  or  unethical  spirit  and  can  hardly  be 
associated  with  ordinary  childish  hysteria. 

Diagnosis. — Without  recounting  details,  it  should  be  emphasized  that  a 
tentative  diagnosis  is  extremely  important  to  the  treatment  of  hysteria.  If 
the  physician  does  not  promptly  establish  his  authority  over  the  child  in  the 
treatment  of  the  hysterical  symptoms,  the  prospect  of  success  through  his 
efforts  becomes  very  doubtful,  and  the  chances  of  ultimate  recovery  rest 
with  the  next  consultant,  or  pass  to  the  quack,  or  to  one  of  the  many  ex- 
ploited "cures."  Nevertheless  a  careful  examination  is  required  in  every 
case,  for  the  hysterical  child  may  be  subject  to  organic  disease  and  error  in 
this  direction  is  unpardonable.  In  fact,  it  is  hardly  ever  safe  to  attach  the 
name  hysteria  to  the  diagnosis  since  the  laity,  and  especially  the  neuro- 
pathic laity,  is  resentful  of  the  term. 

Treatment. — The  treatment  of  hysteria  is  psychical  and  offers  a  favor- 
able outlook.  Serious  cases  do  not  recover  readily  in  the  environment  of 


566  TEXT-BOOK  OF  PEDIATRICS 

the  home.  Remissions  when  the  child  is  returned  to  it  are  frequent.  The 
so-called  miracle  cures  usually  succeed  best  during  a  consultation,  when  the 
child  finds  himself  alone  with  the  physician.  If  it  can  be  avoided,  the  parents 
should  not  be  permitted  to  witness  the  first  attempts  at  treatment.  Still 
greater  success  is  attainable  if  the  patient  is  placed  promptly  in  an  institu- 
tion, a  move  which,  in  itself,  often  suffices  for  the  disappearance  of  the 
symptoms.  At  times,  the  very  fear  of  being  placed  in  an  institution  is 
enough  to  affect  a  cure.  Yet  even  in  such  a  place  the  treatment  may  be 
unsuccessful  if  the  parents  accompany  the  child.  It  is  often  difficult  to  gain 
this  point,  but  the  least  leniency  often  ruins  all  the  chances  of  recovery. 

The  actual  psychical  treatment  employs  two  principal  methods :  (1)  The 
method  of  intentional  neglect.  Care  should  be  taken  that  the  child  does 
not  injure  himself,  beyond  which  the  attacks  are  to  be  entirely  disregarded. 
The  entire  institutional  staff,  including  physicians  and  nurses,  must  be 
fully  instructed.  When  the  child  no  longer  has  spectators  for  his  exhibi- 
tions, they  usually  disappear  spontaneously  in  a  very  short  time. 

(2)  The  second  method  of  treatment  is  that  which  consists  in  the  ele- 
ment of  surprise  (Brans).  The  results  must  be  achieved  before  the  child 
has  time  to  fit  himself  into  his  new  surroundings  or  to  take  a  stand  against 
the  strangers  dealing  with  him.  In  fact,  the  entire  treatment  is  dependent 
upon  a  single  play;  for  if  it  is  not  possible  to  overawe  the  child  or  to  make 
him  conform  at  once  to  the  suggestion  of  the  physician,  he  will  immediately 
realize  that  he  has  not  met  his  master  and  the  outlook  for  recovery  is 
greatly  lessened.  Of  course  the  psychology  of  the  individual  patient  must 
be  considered.  A  harsh  command  or  a  word  may  be  sufficient.  For  in- 
stance, the  seemingly  paralyzed  arm  is  raised  and  at  the  point  of  releasing 
it,  the  patient  is  told  to  "hold  it  there"  (Bruns).  Better  results,  still,  may 
be  gained  with  the  support  of  some  slightly  painful  or  mystifying  method  of 
treatment.  For  this  purpose,  faradization  often  serves  very  well.  If  it  has 
been  already  tried  on  the  child  without  result,  some  other  device,  such  as 
Bier's  stasis,  perspiration-producing  bitter  medicines,  subcutaneous  in- 
jection and  narcosis  in  pseudo-surgical  affections  etc.,  give  better  results. 
In  all  this,  less  depends  upon  what  is  done  than  upon  how  it  is  done.  The 
verbal  suggestion  connected  with  the  treatment  must  be  so  definite  that  the 
child  has  no  room  for  doubts.  It  is  generally  good  policy  not  to  laud  the 
remedy  in  the  presence  of  the  child,  but  rather  to  dilate  upon  its  good  points 
to  the  parents,  so  that  the  child  may  receive  the  suggestion  more  or  less 
indirectly  without  being  able  to  discover  the  immediate  intention.  If  it  is 
possible  to  make  the  recovery  by  means  of  psychical  influence — a  more 
welcome  result — by  reference,  for  instance,  to  the  mother 's  anticipated 
pleasure,  to  the  child's  early  return  to  the  home,  etc.,  the  soil  for  success  is 
all  the  better  prepared.  The  recovery  may  be  reached  by  a  suggestive 
therapy,  operating  progressively,  as  in  the  example  of  abasia  given  above. 
In  hysterical  aphonia  it  may  be  necessary,  to  begin  with,  to  produce  only 
the  vowel  sounds  and  the  rest  of  the  vocalization  gradually  later  on. 

In  still  other  cases,  influence  operates  but  very  slowly  and  gradual  im- 
provement is  secured  by  the  suggestive  method  from  day  to  day.  Where 


DISEASES  OF  THE  NERVOUS  SYSTEM  567 

hysterical  attacks  do  not  disappear  under  intentional  neglect  alone,  it  may 
be  well  to  give  a  cold  bath,  an  electrical  treatment  or  some  other  unpleasant 
measure.  These  measures  should  not  impress  the  child  as  punishments; 
they  must  always  be  suggested  to  him  as  treatment.  If  this  is  not  assured, 
they  will  lose  all  therapeutic  affect.  Quite  similarly,  temporary  isolation, 
the  screening  of  the  bed  and  the  like,  may  be  so  employed.  Hypnosis  must 
be  very  carefully  considered  before  resort  to  it  is  had.  It  should  be  employed 
only  in  very  exceptional  cases.  The  possibility  of  psychic  injury  lies  espe- 
cially close  in  hysteria. 

With  the  relief  of  symptoms  it  still  remains  necessary  to  treat  the 
hysteria  itself.  With  slight  modifications  all  the  methods  described  in  the 
treatment  of  neuropathy  and  neurasthenia  are  applicable  to  this  task 

IV.  PSYCHOSES 

1.  CONGENITAL  AND  EARLY  ACQUIRED  DEFECT  PSYCHOSES 
Feeble-Mindedness;  Idiocy;  Imbecility;  Mental  Debility 

Congenital  or  early  acquired  feeble-mindedness  is  characterized  by  the 
absence  of  psychic  faculties  or  by  increasing  difficulty  in  their  attainment. 
The  intellectual  impairment  is  usually  the  dominant  feature,  but  it  is 
frequently  associated  with  moral  defects.  In  the  milder  forms  of  deficiency 
these  may  fill  the  more  conspicuous  place. 

Etiology. — A  great  variety  of  organic  brain  diseases  may  cause  feeble- 
mindedness. Among  them,  the  more  important  are  cerebral  infantile  palsy, 
meningitis,  and  hydrocephalus.  Very  often  the  sequellse  of  these  diseases 
are  more  or  less  distinctly  discernible,  if  only  in  the  fonn  of  exaggerated 
reflexes,  hyper-  or  hypotonias,  deformities  of  the  cranium,  etc.  In  another 
group  of  idiots,  the  mental  defect  is  traceable  to  cretinism  and  myxedema. 
This  type,  together  with  mongoloid  idiocy,  is  discussed  in  another  division 
of  this  work.  But  while  the  etiology  of  these  cases  is  well-defined,  there 
are  many  others  in  which  the  feeble-mindedness  does  not  seem  to  be  related 
to  any  definite  physical  disease.  Careful  histologic  examinations  often 
show  retardations  or  perversions  of  development  of  the  brain.  In  pro- 
nounced cases  the  brain  proves  to  be  below  normal  in  weight. 

Among  the  causes  of  congenital  feeble-mindedness,  alcoholism  in  the 
parents,  syphilis,  and,  injuries  affecting  the  child  during  its  fetal  de- 
velopment or  in  parturition,  stand  foremost  Mental  deficiencies,  in  vary- 
ing degree,  often  appear  in  children  of  psychopathic  constitution  and 
may  become  a  feature  of  any  of  the  symptom-complexes  which  the  diathe- 
sis presents. 

Symptoms. — The  so-called  stigmata  of  degenerati6n  (see  page  503),  are 
frequently  found.  The  head  is  often  microcephalic,  the  forehead  retreating 
(the  Aztec  type) ;  or  it  may  present  hydrocephalic  and  other  peculiarities  of 
form.  Speech  is  very  often  entirely  wanting  and  the  child  makes  known  its 
wants  by  inarticulate  sounds  or  by  unusually  loud  screams.  In  other  cases 
speech  may  be  possible  but  indistinct,  lisping,  or  otherwise  abnormal. 
Epileptic  convulsions  are  common. 


568 


TEXT-BOOK  OF  PEDIATRICS 


Generally  two  types  of  feeble-mindedness  can  be  distinguished  clinically : 
1.  The  torpid  idiots  who,  undisturbed  by  any  changes  in  the  world  about 
them,  lie  hour  after  hour  upon  the  bed  staring  into  vacancy,  or  often  boring 
the  entire  fist  into  the  mouth.  2.  The  agile  or  versatile  idiots  who,  stirred 
by  the  constant  desire  to  move,  throw  themselves  about  on  the  bed  without 
ceasing,  rock  to  and  fro  incessantly,  run  about  the  room  without  pause,  and 
may  not  be  held  for  more  than  a  moment  by  any  impression.  The  first 

group  is  distinguished  by  an  absolute 
lack  of  attention  and  the  second  group 
by  the  ease  with  which  the  attention 
is  distracted. 

The  pain  sense  is  very  often  dulled 
and  a  pin-prick  is  hardly  noticed.  This 
fact,  as  Thiemich  has  shown,  is  a  good 
objective  sign  for  the  recognition  of 
idiocy  in  childhood.  Frequently  saliva- 
tion is  wanting.  Even  though  there  be 
no  paralyses,  the  patient  is  late  in  acquir- 
ing his  static  functions,  in  learning  to 
hold  up  his  head,  to  sit,  stand  and  walk. 
Many  idiots  have  to  be  fed  all  their  lives 
and  the  training  in  habits  of  cleanliness 
is  a  matter  of  great  difficulty.  Immoder- 
ate masturbation  is  a  common  practice 
with  idiots. 

Imbecility  is  the  term  applied  to  chil- 
dren who  suffer  with  milder  degrees  of 
feeble-mindedness.  They  learn  to  feed 
themselves,  to  walk,  and  to  speak,  and 
are  able  to  master  a  simple  trade.  Very 
mild  grades  of  imbecility  may  go  unrecog- 
nized for  a  long  time.  The  parents  often 
prefer  to  keep  the  sad  truth  hidden  even 
from  themselves  as  long  as  possible.  The 
weak  reasoning  powers  of  the  child  are 
the  less  noticeable  if  the  memory  is 
good,  permitting  the  child  a  memorized 
reproduction  of  his  lessons.  The  mem- 
ory, indeed,  may  be  excessively  developed  in  some  one  direction,  say  for 
numbers,  music,  etc.,  so  that  the  child  may  be  looked  upon,  for  a  time, 
as  a  prodigy.  The  essential  criterion  of  mental  ability,  however,  is  the 
power  to  combine  words  with  ideas,  to  correlate  conceptions  and  to  apply 
them.  Thus  it  is  often  shown  that  in  such  children  the  simplest  conceptions 
of  space,  time,  relationship  and  cause  are  wanting;  as  are  also,  of  course, 
the  higher  abstract  conceptions  of  gratitude,  truthfulness,  envy,  etc.  Scien- 
tific tests  of  intelligence,  chiefly  by  the  methods  of  Ziehen  and  Binet  take 
all  these  things  into  consideration.  By  the  aid  of  colored  skeins,  picture 


FIG.  14C. — Five-year-old  versatile  idiot. 


DISEASES  OF  THE  NERVOUS  SYSTEM  569 

books,  toys,  short  stories,  etc.,  this  is  not  a  difficult  matter,  after  the  child 
has  conquered  his  first  timidity.  With  children  who  tire  easily,  the  tests 
may  not  be  completed  at  one  sitting.  Into  their  further  detail  we  cannot 
enter  here. 

The  term  mental  debility  covers  the  mildest  grades  of  feeble-mindedness. 
Children  of  this  type  are  able  to  keep  up  with  their  school  work  in  a  meas- 
ure and  by  one  means  or  another  they  may  even  gain  the  higher  classes  in 
High  School,  beyond  which  they  seldom  go.  Not  infrequently  their  ethical 
defects  are  more  pronounced  than  their  intellectual  weaknesses.  Some  of  the 
cases,  described  as  psychopathically  weak,  belong  in  this  group.  The 
primary  lack  of  esthetic  sense  and  moral  principle,  when  it  accompanies 
feeble-mindedness,  is  called  moral  insanity. 

The  moral  defect,  however,  can  be  charged  to  intellectual  weakness 
only  when  physical  and  mental  impairment  and  diminished  reasoning  power 
can  be  determined;  when  evil  associations,  lack  of  proper  home  care,  and 
other  similar  factors  can  be  excluded;  and  when  neither  punishment  nor 
rewards  have  any  effect  (Ziehen). 

Diagnosis. — In  the  young  infant  the  awakening  mind  is  heralded  by 
glances  directed  to  bright  objects,  or  to  the  mother,  and  later  by  the  reach- 
ing out  of  the  hand  toward  them.  If  these  indications  do  not  appear,  there 
is  good  reason  to  suspect  a  low  degree  of  intelligence,  provided,  of  course, 
that  the  sense  organs  are  normally  developed.  Later,  the  lowered  reaction 
to  pain  is  evident.  The  delayed  development  of  speech,  as  late  even  as  the 
third  year,  may  by  no  means  be  identified  with  mental  weakness,  especially 
where  the  first  child  of  the  family  is  concerned  and  evidence  obtains  that  he 
understands  spoken  words.  Deaf-mutes  are  often  mistaken  for  idiots  and 
their  mental  development  is  neglected  in  a  most  irresponsible  manner. 
Special  caution  must  be  given  that  myxedema  be  not  overlooked,  since 
good  results  may  be  achieved  by  its  proper  treatment. 

Treatment. — Treatment  directed  against  the  cause  of  the  mental  con- 
dition is  possible  of  success  only  in  myxedema,  cretinism  and,  possibly,  con- 
genital lues.  Beyond  this,  thoroughly  individualized  pedagogic  treatment 
which  differs  broadly,  alike  in  its  aims  and  its  methods,  from  the  ideals  of 
the  general  school,  is  the  only  thing  that  will  really  help  these  children.  The 
results  which  may  be  obtained  by  good  institutional  training  are  sometimes 
very  satisfactory,  although  the  high  expectations  of  the  parents  are  often 
grievously  disappointed.  The  earlier  the  child  is  placed  in  such  an  institu- 
tion, and  this  especially  if  the  home  environment  is  not  all  that  it  might  be, 
the  more  beneficial  is  the  treatment  of  the  child.  The  expense  of  main- 
taining markedly  deficient  children  and  those  who  are  especially  difficult  to 
train,  may  be  very  high.  Special  schools,  rapidly  becoming  more  numerous, 
accomplish  very  brilliant  results.  It  is  generally  possible  to  train  the 
majority  of  imbeciles  to  a  trade. 

2.  ACQUIRED  DEFECT  PSYCHOSES 

Under  this  heading  may  be  classed  the  amaurotic  familial  idiocies 
(page  523),  diffuse  cerebral  sclerosis  (page  510),  and  some  forms  of  brain 


570  TEXT-BOOK  OF  PEDIATRICS 

syphilis  and  of  epilepsy.  Two  specific  mental  diseases  of  this  group 
are  important. 

(a)  Progressive  Paralysis. — This  disease  has  been  described  very  often 
in  childhood  as  the  result  of  congenital  lues.  Its  onset  occurs  during  the 
second  decade.  The  first  physical  disturbances  are  those  of  speech,  syllab- 
ication, bradylalia,  etc.;  fixation  of  the  pupils;  loss  of  facial  expression; 
tremor  of  the  lips;  and,  later,  inability  to  walk,  intention  tremor  and 
cachexia.  The  patellar  reflexes  are  present  and  often  exaggerated.  Tabetic 
symptoms,  optic  atrophy,  lancinating  pains,  etc.,  are  very  rarely  observed 
simultaneously.  The  psychic  disturbances  consist  in  a  progressive  loss  of 
the  mental  faculties,  which  may  lead  to  complete  dementia.  They  often 
play  a  significant  part  in  the  disease-picture  from  the  very  beginning.  The 
patient  usually  feels  perfectly  well.  Hallucinations  and  delusions  of  gran- 
deur are  observed  only  occasionally;  while  the  so-called  paralytic  attacks, 
with  dizziness,  unconsciousness,  epileptoid  convulsions,  or  headache,  are 
common.  The  disease  generally  lasts  for  three  or  four  years. 

In  its  treatment  nucleinic  acid  may  be  considered. 

HEBEPHRENIA;  CATATONIA  OR  DEMENTIA  PR^ECOX 

The  beginning  of  these  psychoses  appears,  as  a  rule,  during  puberty. 
The  disease  may  occasionally  develop  before  the  tenth  year.  At  the  onset, 
the  condition  is  readily  mistaken  for  neurasthenia  or  even  hysteria.  For 
detailed  descriptions,  the  reader  must  be  referred  to  text-books  of  psychiatry. 

PSYCHOSES  WITHOUT  DEFECTS  OF  INTELLIGENCE 

Concerning  these  psychoses,  it  may  be  said,  merely,  that  melancholia 
and  mania  occur  in  children;  that  acute  hallucinatory  insanity  (amentia), 
has  been  observed;  while  chronic  paranoia  is  extremely  uncommon.  The 
manifestations  of  each  of  these  diseases  resemble  very  closely  the  course 
they  take  in  the  adult. 


vra. 

THE  ACUTE  INFECTIOUS  DISEASES 

BY 


£. 

Zurich. 

REVISED  AND  EDITED  BY 
E.  C.  FLEISCHNER,  M.D., 

Clinical  Professor  of  Pediatrics,  University  of  California 
and 

K.  F.  MEYER,  M.D., 

Professor  of  Research  Medicine,  University  of  California. 

GENERAL  CONSIDERATION 

DISEASES  caused  by  micro-organisms,  frequently  associated  with  con- 
stitutional symptoms  and  directly  or  indirectly  transmissible  from  person 
to  person,  play  a  prominent  part  in  general  mortality  and  morbidity.  The 
role  which  certain  of  the  more  important  of  these  diseases  take  is  shown  in 
the  following  table  ; 

ANNUAL  MORTALITY  (AFTER  RAT.HMAN) 


Diseases 

1891-1900 

1901-1903 

1910 

Diphtheria  

30,400 

12,700 

9,700 

Pertussis       

14,000 

11,900 

9,300 

Measles  

8,400 

8,400 

7,300 

Scarlet  Fever  

8,000 

9,700 

5,500 

These  comparative  statistics,  are,  of  course,  not  fixed.  In  the  past 
decade,  the  deaths  due  to  diphtheria  have  decreased  materially,  although 
during  the  last  few  years  they  have  again  increased  in  Germany. 

The  above  named  infectious  diseases,  with  a  number  of  others,  show  a 
special  predilection  for  childhood,  so  that  they  have  come  to  be  known  as 
Diseases  of  Childhood.  Reliable  morbidity  statistics  of  entire  countries 
are  not  obtainable,  however,  at  the  present  time  but  mortality  statistics 
which,  taken  as  a  whole,  may  be  said  to  run  parallel  to  them  give  valuable 
information.  Thus,  in  Bavaria,  from  1893  to  1902;  out  of  100,000  deaths 
among  the  male  population,  the  following  table  (after  Prinzing),  shows 
those,  that  are  attributable  to  each  of  the  four  principal  infectious  diseases 
at  various  ages  of  life. 

571 


572 


TEXT-BOOK  OF  PEDIATRICS 


Ag 

es 

0-1 

1-2 

2-5 

5-10 

10-20 

20-30 

Scarlet  Fever  

27 

52 

45 

19 

5  9 

0  6 

Measles  

319 

435 

73 

13 

1  8 

0  2 

Diphtheria  and  Croup  

138 

401 

277 

77 

15  8 

0  7 

Pertussis  

674 

295 

38 

39 

02 

00 

From  this  summary  it  will  be  seen,  that  the  significance  of  pertussis 
and  measles  sinks  to  an  unimportant  minimum  after  the  fifth  year  and 
that  scarlet  fever  and  diphtheria  fail  of  significance  after  the  tenth  year. 

Individually  considered,  these  four  important  infectious  diseases  show 
peculiar  differences  as  to  the  ages  at  which  they  prevail.  This  may  be 
clearly  seen  in  a  graphic  presentation  of  their  relative  occurrence  during 
the  early  years  of  life,  taken  from  the  excellent  statistics  of  Basel,  Switzer- 
land. A  comparison  may  be  made  of  the  details  in  each  individual  disease. 

Pathogenesis. — It  must  be  assumed  that  the  basic  theory  of  immunity 
is  thoroughly  comprehended.  The  understanding  of  this  theory  is  of  great 
significance  in  the  infectious  diseases  of  childhood,  and  particularly  with 
reference  to  diphtheria  and  its  serum  therapy.  It  does  not  present  any 
differences  in  principle  as  applied  to  childhood  from  those  which  obtain  in 
the  adult.  It  may  be  briefly  stated,  as  a  matter  of  general  acceptance,  that 
during  the  period  of  incubation  of  many  infectious  diseases,  antibodies, 
specific  to  the  infective  organism  or  its  toxins,  are  formed.  It  is  held,  fur- 
ther, as  von  Pirquet  and  Schick  have  practically  proven,  that  the  disease 
begins  when  the  formation  of  antibodies  is  complete,  representing,  indeed, 
the  reaction  between  the  antibodies  and  the  specific  toxins.  Many  acute 
exanthemata,  such  as  variola,  varicella  and  measles,  closely  resemble  the 
serum  disease,  which  follows  a  first  injection  or  an  initial  vaccination.  A 
hypersensitivity  is  observed  only  upon  reinfection;  as,  for  instance,  in 
hemorrhagic  small-pox,  a  virulent  form  which  occurs  almost  invariably 
in  those  vaccinated  persons  who  exceptionally  succumb  to  the  disease. 
Moro  accounts  for  the  rash,  not  as  the  result  of  the  action  of  agglutinins, 
but  as  a.  manifestation  of  a  specific  hypersensitivity,  which  is  analogous 
to  the  serum  and  tuberculin  exanthems. 

The  transmission  of  the  acute  infectious  diseases  is  generally  a  matter 
of  contagion;  that  is,  infectious  material  developed  in  the  one  patient  passes 
directly  to  another,  in  whom  the  disease  is  thus  produced.  In  several  of 
these  diseases  transmission  is  chiefly  through  the  medium  of  the  air  most 
frequently  by  so-called  droplet  infection,  which  means  that  small  particles  of 
mucus  containing  the  specific  organism  are  discharged  by  the  act  of  sneez- 
ing or  coughing  and  are  then  inspired  or  drawn  into  the  mouth  of  neighbor- 
ing persons.  Infection  by  this  droplet  method  occurs  most  readily  and 
frequently  in  diseases  of  the  respiratory  passages,  where  the  specific  micro- 
organisms abound.  It  is  a  common  experience  in  measles,  pertussis,  and 
influenzal  disorders  and  an  occasional  one  in  varicella.  No  doubt  of  this 
method  of  transmission  existed  even  prior  to  our  present  advanced  knowl- 


THE  ACUTE  INFECTIOUS  DISEASES 


573 


edge  of  bacteriologic  causes. 
These  diseases  have  these  facts 
in  common — that  infection  by 
aspiration  is  almost  without 
exception  a  matter  of  direct 
conveyance  from  one  person 
to  another;  and  that  conta- 
gion carried  by  means  of  in- 
fected objects  or  by  healthy 
persons  in  immediate  contact 
with  the  patient  is  exception- 
ally rare,  since  the  specific 
organisms  soon  perish,  when 
they  are  removed  from  the 
human  body.  It  is  easy  to 
see,  therefore,  that  the  origin 
of  the  infection  in  measles, 
whooping-cough  and  influenzal 
disorders  is  readily  determined. 
This  droplet  infection  may 
be  an  active  agency  in  many 
other  infectious  diseases,  but  it 
is  evident  that  it  will  operate 
only  when  the  infective  organ- 
isms are  in  the  mouth  or  the 
upper  air  passages.  Attention 
has  been  called  to  this  possible 
means  of  transmission  in  scar- 
let fever  and  diphtheria,  which 
are  among  the  most  important 
of  the  diseases  of  childhood, 
but  as  an  actual  fact  it  is  prob- 
ably a  quite  uncommon  thing. 
In  these  diseases  contact  infec- 
tion plays  a  most  active  part. 
The  specific  organisms  are  con- 
tained in  the  secretions  of  the 
patient's  mouth  and  nose  and 
are  transferred  to  others  by 
direct  contact.  The  germs, 
therefore,  usually  gain  admis- 
sion through  the  mouth  and 
less  often  through  the  nose.  In 
these  two  diseases,  as  in  many 
others,  indirect,  as  well  as  direct 
contact,  is  to  be  considered  as 
a  means  of  conveyance.  Thus 


PERTUSSIS 


8% 

C% 

lr% 

2.% 

5% 
f>% 
3% 
S% 
1% 

3% 

O-3 

-6      -0      -72          -J8                -ZLMorwt* 

MEASLES 

0-3 

-6       -o      -12         -  /«•?              -  Z'rMonaia 
DIPHTHERIA 

z% 

1% 

-r-T~ 

O-3      -6       -9       -72 


-z^Monate 


SCARLET  FEVER 


Fio.   147. — Predisposition  of  age  to  various  infectious 
diseases  during  first  twenty-four  months. 


574  TEXT-BOOK  OF  PEDIATRICS 

the  micro-organisms  may  be  spread  to  healthy  persons,  by  handkerchiefs, 
vomitus,  food-stuffs,  etc.,  and  thence  may  be  distributed  to  those,  who 
have  not  been  in  direct  touch  with  the  patient.  This  indirect  contact  be- 
comes significant  only  when  the  germs  are  able  to  survive  for  a  variable 
period  outside  of  the  human  body.  rThis  is  actually  true  in  scarlet  fever, 
diphtheria,  typhoid  fever,  small-pox,  German  measles,  mumps,  etc.  It 
accounts  for  the  fact,  that  in  these  diseases  the  method  of  transmission  and 
the  source  of  infection  often  remain  wholly  obscure.  In  scarlet  fever, 
particularly,  the  specific  virus  lives  for  a  very  long  while  after  removal 
from  the  infected  body. 

The  question  of  individual  predisposition,  upon  which  the  development 
of  each  and  every  case  depends,  is  still  in  many  respects  obscure,  on  account 
of  the  fact,  that  the  significance  of  many  influencing  elements,  such  as  the 
virulence  of  the  specific  organism  and  the  opportunities  of  infection,  is 
still  unknown. 

The  relative  predisposition  to  disease  at  certain  ages,  already  noted, 
depends  mainly  upon  the  fact  that  such  disease  is  commonly  incurred 
earlier  in  life.  This  fact  comes  out  very  clearly  in  the  case  of  measles.  One 
attack  of  the  disease  almost  invariably  immunizes  the  child  for  the  remain- 
der of  his  life.  A  second  attack  of  measles  is  extremely  rare.  Since  the 
susceptibility  to  measles  is  very  general  by  the  end  of  the  first  year  and 
since  almost  all  children  of  the  present  day  are  exposed  to  contagion  at 
some  time  or  other  during  their  early  childhood,  measles  has  come  to  be 
regarded,  under  ordinary  circumstances,  as  a  disease  of  childhood,  despite 
the  fact,  that  adults  are  naturally  as  susceptible  to  it  as  are  children. 

Many  other  infectious  diseases  give  a  certain  degree  of  immunity  after 
one  attack.  We  possess,  however,  very  uncertain  knowledge  of  such  immu- 
nity. Not  alone  in  measles,  but  also  in  small-pox,  this  acquired  immunity 
is  undoubtedly  of  great  importance,  but  it  is  not  so  definitely  demonstrable 
in  the  latter  disease.  The  measure  of  immunity  ordinarily  accepted  in 
such  diseases  as  pertussis  and  scarlet  fever  is  certainly  misunderstood  or 
over-estimated,  a  fact  to  which  Gottstein  very  justly  calls  attention.  In 
diphtheria  acquired  immunity  evidently  persists  for  but  a  very  short  time. 

Granting  that  survival  from  single  attacks  of  certain  infectious  diseases 
confers  a  lasting  immunity,  it  still  remains  true,  that  childhood  has  a  special 
predisposition  to  a  number  of  these  disorders.  Many  persons,  either  in 
later  childhood  or  adult  life,  who  have  never  had  these  diseases  do  not 
become  ill  even  when  exposed  to  infection,  to  which  many  younger  indi- 
viduals will  succumb.  Chicken-pox  is  an  illustration  in  point. 

Again,  most  people  have  measles,  sooner  or  later,  and  many  have  per- 
tussis, whereas  a  large  number  never  have  scarlet  fever  and  diphtheria. 
Gottstein  has  attempted  to  express  in  numerical  terms  the  disposition  to 
particular  diseases  in  various  epidemics  by  means  of  the  so-called  conta- 
gion index.  He  has  estimated  the  liability  to  measles  at  95  per  cent.;  to 
scarlet  fever  at  40  per  cent.;  and  to  diphtheria  at  10  per  cent,  to  15  per  cent. 
These  figures,  of  course,  are  of  only  relative  value,  but  nevertheless  they 
show  an  actual  difference  in  disposition  to  the  three  diseases  named.  The 


THE  ACUTE  INFECTIOUS  DISEASES  575 

explain  why  measles  epidemics  spread  rapidly,  while  scarlet  fever  epi- 
demics are  of  slower  development  and  diphtheria  epidemics  are  very  slow 
to  spread. 

The  reason  for  the  greater  predisposition  of  childhood  to  certain  dis- 
eases is  still  far  from  clear.  As  compared  with  that  of  adults  it  may  be  due 
in  part  to  the  lower  resistance  and  in  part  to  the  greater  permeability  of 
the  mucous  membranes,  which  serve  as  ports  of  entry  for  micro-organisms. 
Both  mechanical  and  morphological  conditions  may  play  some  part  in 
explanation  of  the  fact,  that  the  adult  mucous  membranes,  with  their 
denser  epithelium,  and  particularly  those  of  the  nose,  the  tonsils  and  the 
pharynx,  present  a  more  effectual  barrier  to  the  invaders.  Neither  inborn  nor 
acquired  has  the  child  any  very  extensive  mechanism  of  defense  by  way  of 
bactericidal  or  other  protective  bodies.  In  many  cases  the  chances  of  infec- 
tion are  favored  by  lesions  of  the  mucous  membranes  incident  to  catarrhal 
or  other  inflammations.  This  accounts  for  the  prevalence  of  diphtheria 
and  croup  in  those  seasons  in  which  diseases  of  the  respiratory  organs  pre- 
vail, and  it  also  suggests  the  reason  for  the  predisposition  of  children  sick 
with  measles  to  secondary  infection  with  croup.  The  tendency  of  patients 
with  a  lymphatic  diathesis  to  diphtheria,  scarlet  fever,  and  other  infectious 
diseases  is  the  result  of  an  evidently  lowered  resistance,  due  to  the 
constitutional  disturbance,  to  the  organic  changes,  such  as  adenoid  hyper- 
trophy and  the  chronic  pharyngitis  it  favors,  which  prepare  soil  for  the 
germ  invasion. 

It  must  be  said,  however,  that  there  are  infectious  diseases  to  which 
youthful  predisposition  is  so  strong,  that  the  individual  is  attacked  whether 
the  local  mucous  membranes  are  normal  or  impaired.  This  is  true  of 
measles  and  influenza.  On  the  other  hand  the  lesions  which  the  infectious 
disease  produces  in  the  mucous  membranes  very  greatly  favor  the  occur- 
rence of  secondary  infections  caused  chiefly  by  pyogenic  organisms,  of  the 
strepto-  staphylo-  or  pneumococcic  forms.  These  secondary  infections 
determine  the  course  of  the  disease  in  a  very  large  number  of  infectious 
disorders  and  are  the  cause  of  the  major  number  of  resulting  deaths. 

While  infancy,  as  compared  with  later  childhood,  shows  a  lesser  pre- 
disposition to  the  true  acute  infectious  diseases,  at  no  age  is  the  tendency 
to  local  and  general  infection  with  pyogenic  organisms  so  great.  This  is 
especially  true  of  the  new-born  and  of  infants  during  the  first  few  months. 
It  is  to  be  explained  by  the  tenderness  of  the  skin  and  mucous  membranes, 
by  the  lessening  of  immunity  resulting  from  disturbances  of  nutrition  in 
artificially-fed  infants,  and  by  the  frequent  existence  of  the  exudative  dia- 
thesis. All  of  these  factors  may  be  concurrent  and  may  tend  to  increase 
the  liability  to  infection  and  to  decrease  the  resistance  of  the  young  infant. 
These  facts  are  more  fully  discussed  under  the  chapters  upon  Diseases  of 
the  New-born  and  upon  General  Sepsis. 

The  origin  of  epidemics  is  not  very  fully  understood.  It  is  clear  in  mea- 
sles alone.  In  the  case  of  this  disease  an  epidemic  is  usually  lighted  up  at 
regular  intervals  of  a  few  years,  with  the  accumulation,  as  it  were,  of  a  suf- 


576  TEXT-BOOK  OF  PEDIATRICS 

ficient  number  of  children  of  susceptible  age.  In  other  diseases  the  causes 
of  recrudescence  are  generally  obscure.  In  many  epidemics  an  exaggerated 
virulence  of  the  provocative  organism  must  be  admitted.  Illustration  of 
this  factor  is  found  in  the  serious  epidemic  of  scarlet  fever,  which  occurred 
in  England  in  the  middle  of  the  last  century.  This  outbreak  was  so  severe 
as  to  suggest  the  special  predisposition  of  the  Anglo-Saxon  race,  but  it  has 
been  necessary  to  abandon  this  theory  in  view  of  the  extraordinary  reces- 
sion of  the  disease  in  England  during  the  last  twenty  years. 

In  diphtheria  it  is  possible  to  test  the  question  of  virulence  of  the  organ- 
isms on  guinea  pigs.  It  is  not  uncommon  to  find  a  very  high  degree  of 
virulence  in  some  severe  epidemics  or,  instead,  severe  single  cases  without 
any  demonstrable  regularity  in  their  occurrence.  General  experience  goes 
to  show,  that  in  serious  epidemics  and  in  groups  of  especially  severe  cases 
a  larger  percentage  of  adults  than  usual  will  be  found  to  be  affected. 

The  opportunities  of  infection  are  very  much  greater  in  children  than 
in  adults.  They  are  fostered  by  the  intimate  association  of  children  in  the 
home  and,  in  general,  by  their  gatherings  in  day  nurseries,  schools,  etc. 
The  transmission  of  contagion  is  greatly  encouraged  among  children  by 
their  habitual  carelessness  in  the  disposal  of  their  secretions  and  excretions. 
They  are  apt  to  soil  face  and  hands  and  clothing  with  mucous  discharges 
from  the  nose  and  mouth  and  thus  the  infected  material  is  spread  directly 
or  indirectly.  The  communistic  use  of  handkerchiefs  and  the  close  contact 
of  children  with  the  floors  in  creeping  and  playing  add  to  the  ample  oppor- 
tunities of  infection.  Such  diseases  as  diphtheria,  which  are  readily  spread 
by  direct  contact,  are  encouraged  by  the  uncleanliness  of  the  sick  or  their 
surroundings.  Dirt-conveyed  diseases  are  more  common  among  those  of 
meagre  circumstances  than  they  are  among  the  scrupulously  clean.  Young 
infants  enjoy  a  comparative  protection  from  these  numerous  opportunities 
of  infection,  since  they  move  about  less  freely,  are  relatively  isolated,  and 
so  come  less  directly  in  contact  with  other  children. 

The  importance  of  isolation,  as  a  means  of  prevention,  is,  of  course,  to 
be  emphasized  in  those  diseases,  which  spread  directly  from  one  person  to 
another.  General  experience  shows,  that  among  those  of  inferior  social 
condition,  contagion  will  involve  entire  families  in  their  earlier  years.  Chil- 
dren living  in  crowded  quarters  have  measles  during  their  early  childhood, 
especially  when  they  are  grouped  in  day  nurseries,  kindergartens,  etc. 
Among  the  middle  classes  the  disease  is  apt  to  occur  at  school  age,  while 
the  children  of  the  wealthy,  reared  in  careful  seclusion,  often  escape  attack 
until  maturity. 

Formerly,  the  occasional  combinations  of  different  infectious  diseases, 
especially  the  acute  exanthemata,  aroused  particular  attention.  Since, 
however,  we  have  learned  that  each  of  these  diseases  is  the  product  of  a 
specific  organism,  the  association  of  two  or  more  types  of  infection  is  no 
longer  deemed  remarkable  and  is  of  interest  only  as  it  makes  a  diagnosis 
more  difficult  and  prolongs  the  course  of  the  illness.  The  combination  of 
measles  and  scarlet  fever,  of  measles  or  scarlet  fever  with  diphtheria,  or  of 


THE  ACUTE  INFECTIOUS  DISEASES  577 

any  of  these  diseases  with  chicken-pox,  is  not  unusual  and  may  even  become 
common,  if  the  possibilities  of  hospital  isolation  are  not  of  the  most  effec- 
tive order. 

As  a  genera]  rule  the  combination  of  any  of  these  diseases  does  not  effect 
their  individual  behavior  to  any  great  extent.  When  two  severe  infections 
are  combined  the  prognosis  is,  of  course,  less  favorable.  At  times,  the  incu- 
bation period  of  one  disease,  as  in  measles,  is  extended  by  the  intercurrency 
of  some  other  infectious  disorder.  The  writer  has  seen  the  onset  of  chicken- 
pox  interrupted  by  the  development  of  pneumonia  and  its  course  continued 
after  the  pneumonia  crisis  has  passed.  The  addition  of  a  second  infection 
to  measles  may  readily  aggravate  the  attack  and  lead  to  the  most  danger- 
ous results.  This  is  especially  true  of  the  secondary  appearance  of  diph- 
theria, the  spread  of  the  latter  into  the  larynx  and  the  trachea  in  such  an 
event  being  encouraged  and  often  with  fatal  consequences. 

The  measles  patient  shows  a  distinct  want  of  resistance  to  tuberculosis. 
Again,  the  appearance  of  measles  during  pertussis  is  a  serious  matter,  since 
not  infrequently,  it  leads  to  grave  pulmonary  complications.  The  same 
tendency  is  frequently  noticed  if  measles  is  complicated  with  scarlet  fever. 

Convalescence  from  an  infectious  disease  is  variable  in  different  indi- 
viduals. Recovery  is  usually  complete.  In  certain  cases  the  attack  may 
be  followed  by  persistent  and  often  obstinate  sequelae.  Catarrh  frequently 
remains  after  pertussis  or  measles,  while  deafness,  heart  lesions,  and  nephri- 
tis follow  scarlet  fever.  Sometimes  an  exudative  diathesis  may  develop, 
especially  after  measles  or  chicken-pox.  Tuberculosis  is  frequently  acti- 
vated by  measles. 

On  the  other  hand,  it  is  not  uncommon  to  find,  that  the  general  health 
of  the  child  improves  after  an  infectious  disease.  The  author  has  observed 
such  improvement  very  distinctly  in  cases  of  pertussis. 

In  the  prognosis  of  these  disorders  a  large  number  of  factors  must  be 
taken  into  account,  which  have  little  or  no  significance  in  the  adult.  The 
better  prognosis  in  the  case  of  breast-fed  children  over  the  artificially-fed 
is  always  recognized.  The  influence  of  care  and  environment  is  enormous. 
The  outcome  more  often  depends  upon  these  factors  than  upon  the  nature 
of  the  disease.  Particularly  do  they  govern  the  result  in  those  disorders 
in  which,  as  in  measles  and  pertussis,  secondary  infections  are  of  decisive 
influence.  Rickets,  the  prevailing  malady  of  early  life  among  the  poor, 
also  has  a  marked  effect  upon  the  course  of  contagious  disease.  Special  sig- 
nificance must  be  given  to  certain  diatheses.  Particularly  unfavorable  is  the 
presence  of  a  marked  exudative  or  lymphatic  tendency.  It  is  most  felt  in 
diphtheria  and  scarlet  fever.  Fat,  pasty  children,  with  eczema,  often  suc- 
cumb with  unexpected  rapidity  by  the  second  or  third  day  even  when  the 
disease  itself  is  not  of  severe  grade.  Neuropathic  patients  are  usually 
affected  with  undue  intensity  and  together  with  spasmophilics,  suffer  se- 
verely from  pertussis. 

Prophylaxis  presents  numerous  problems.  In  diseases,  -such  as  rubella, 
which  are  always  mild,  it  may  be  practically  disregarded.  In  infections 
which  are  difficult  of  avoidance,  as  measles  and  pertussis,  but  which  gener- 
37 


578  TEXT-BOOK  OF  PEDIATRICS 

ally  pursue  a  mild  course  in  older  children,  prophylactic  measures  should 
safeguard  the  first  three  or  four  years  of  life.  Since  few  permanently  escape 
measles,  pertussis  or  chicken-pox,  and  since  they  are  apt  to  be  more  severe 
in  adult  life,  it  is  hardly  desirable  to  safeguard  robust  children  in  later 
childhood  from  these  diseases  too  scrupulously. 

Everything  should  be  done,  however,  to  avoid  such  serious  infectious 
diseases  as  scarlet  fever  and  diphtheria,  the  outcome  of  which  we  can 
never  be  assured.  To  this  end,  the  most  important  measure  is  the  absolute 
isolation  of  the  patient  and  his  nurse,  a  measure  possible  in  but  very  few 
homes.  In  view  of  this  limitation  it  is  urgently  necessary,  that  all  cases  of 
scarlet  fever  and  diphtheria  occurring  in  homes  that  do  not  permit  such 
strict  isolation,  should  be  removed  to  a  hospital.  In  order  to  make  this 
rule  broader  of  application,  it  is  very  desirable,  that  the  private  physician 
of  the  larger  cities  be  permitted  to  treat  his  cases  in  the  hospital. 

To  fully  accomplish  the  ends  of  isolation  the  attendant  should  receive 
full  instructions  directly  from  the  physician  and  rigorously  observe  them. 
As  details  worthy  of  mention,  the  provision  of  separate  utensils,  the  disin- 
fection of  the  hands,  and  the  use,  if  possible,  of  a  separate  toilet  for  the 
sick  room  suggest  themselves.  The  physician  himself  should  wear  a  gown 
when  entering  the  room  of  a  patient  with  diphtheria  or  scarlet  fever  and 
should  wash  his  hands  and  face  upon  leaving.  The  excreta  must  be 
disposed  of  with  great  care  and  especially  in  typhoid  fever  should  be  first 
disinfected.  The  same  precautions  should  be  observed  in  handling  the  se- 
cretions from  the  mouth  and  nose  in  diphtheria  and  scarlet  fever.  Effective 
isolation  throughout  the  course  of  a  case  of  infectious  disease  in  the  home, 
pains  being  taken  to  see  that  infected  utensils  are  not  removed  from  the 
room  and  that  random  intercourse  between  the  nursing  attendant  and  the 
family  is  not  allowed,  is  of  far  more  moment  than  later  disinfection. 

Nevertheless,  after  the  patient  has  recovered,  a  thorough  disinfection 
of  the  sick  room  and  of  all  articles  used  in  it  is  in  order.  The  room  should 
be  fumigated  with  formaldehyde;  the  clothing  and  the  bedding  sterilized 
with  steam;  and  books  and  other  articles  washed  with  a  solution  of  bichlo- 
ride  of  mercury  or  phenol.  Too  much  must  not  be  expected  from  such 
measures.  Every  now  and  then  new  cases  will  develop,  in  spite  of  the  exer- 
cise of  the  greatest  care;  and,  conversely,  no  spread  of  the  disease  may 
occur,  though  all  the  precepts  of  cleanliness  have  been  neglected. 

Again,  of  far  more  importance  are  the  principles  of  prevention  addressed 
to  increasing  the  resistance  of  the  child  to  infectious  disease;  especially  in 
the  way  of  rational  living  and  a  suitable  dietary.  Aside  from  the  general 
promotion  of  physical  vigor,  care  should  be  taken  to  avoid  rickets  and  tuber- 
culosis and  to  meet  an  exudative  diathesis  by  proper  treatment.  While 
isolation  is  essential  in  all  the  more  important  infectious  diseases,  subse- 
quent disinfection  is  especially  important  in  scarlet  fever  and  diphtheria, 
whereas  after  measles  and  pertussis  it  is  entirely  uncalled  for. 

The  physician  has  certain  duties  to  perform  as  the  guardian  of  the  pub- 
lic health,  which  for  the  protection  of  the  schools  are  specifically  prescribed 
by  law  in  many  states. 


579 

Children  suffering  from  any  contagious  disease,  though  it  be  but  Ger- 
man measles,  must  be  kept  out  of  school  during  the  course  of  their  illness. 
Unless  superseded  by  state  or  local  law,  the  following  precautionary  mea- 
sures may  be  recommended.  Children  should  not  attend  school  until  three 
weeks  have  elapsed  from  the  onset  of  measles,  reckoning  the  period  from 
the  appearance  of  the  rash.  Following  pertussis,  they  may  be  readmitted 
when  the  cough  has  entirely  disappeared.  In  the  event  of  diphtheria  they 
should  be  kept  away  from  other  children  for  at  least  fourteen  days  after 
the  membrane  has  disappeared.  Convalescents  from  diphtheria  should 
not  be  allowed  to  come  in  contact  with  healthy  individuals  until  two  nega- 
tive cultures  have  been  obtained  from  the  nose  and  throat  at  five  day  inter- 
vals. The  Health  Board  regulations  in  different  states  are  unfortunately 
extremely  variable  on  this  point.  In  scarlet  fever  they  must  not  be  allowed 
to  reenter  earlier  than  eight  weeks  after  the  outbreak  of  the  disease;  and 
certainly  not  until  they  have  completely  recovered  from  such  complica- 
tions as  otitis  media,  etc.  After  this  disease,  the  disinfection  of  the  clothing 
and  the  repeated  bathing  of  the  body  are  very  important. 

If  a  case  of  contagious  disease  appears  in  a  family,  the  well  members 
must  be  excluded  from  school  for  two  weeks  following  an  outbreak  of  diph- 
theria and  for  three  weeks  after  the  onset  of  scarlet  fever.  This  depends 
upon  local  health  regulations,  but  in  a  general  way  it  may  be  said,  that 
contacts  in  diphtheria  should  be  considered  potential  carriers  until  by 
culture  they  are  proven  to  be  otherwise.  If  the  patient  has  been  promptly 
removed  from  the  home  the  other  children  may  be 'readmitted  to  school 
eight  days  subsequent  to  the  invasion  of  diphtheria  arid  fourteen  days  fol- 
lowing the  removal  of  a  case  of  scarlet  fever.  If  measles  invades  a  family, 
the  children,  who  have  not  had  the  disease  and  are  less  than  six  years  of 
age  should  be  kept  away  from  other  small  children  for  the  space  of  three 
weeks.  The  unaffected  members  of  a  family  in  which  pertussis  has  appeared 
should  neither  be  permitted  to  attend  kindergarten  nor  be  placed  in  any 
day  nurseries  during  the  entire  duration  of  the  cough  of  the  sick  child. 
Similarly,  the  older  children  in  such  a  family  should  be  kept  out  of  school. 

The  State  which,  by  strenuous  preventive  measures  has  accomplished 
wonders  against  small-pox,  cholerg,  and  plague,  should  make,  in  some 
localities,  an  equally  strong  effort  to  suppress  other  prevalent  infectious 
diseases.  This  could  be  done  by  the  free  treatment  in  public  hospitals  of 
diphtheria  and  scarlet  fever,  and,  perhaps,  of  measles  and  pertussis  as  well, 
by  the  free  transportation  of  such  patients  in  special  railway  cars  and,  in 
cities,  in  special  ambulances,  and  by  the  creation  of  special  playgrounds  for 
those  who  have  whooping-cough,  etc. 

SCARLET  FEVER 

Scarlet  fever  is  a  specific  exanthematous  infectious  disease,  character- 
ized by  angina  and  erythematous  rash  and  a  tendency  to  peculiar  sequelae. 
The  disease  was  accurately  described  for  the  first  time  by  Sydenham  of 
London,  at  the  end  of  the  seventeenth  century,  who  sharply  differentiated 
it  from  other  exanthemata. 


580  TEXT-BOOK  OF  PEDIATRICS 

Etiology. — Its  causative  organism  is  still  unknown.  By  some  observers 
a  specific  streptococcus,  persistently  found  in  necrotic  and  purulent  tissues, 
often  in  the  blood  itself,  and  appearing  even  in  mild  cases,  is  considered  the 
essential  cause;  but  this  relationship  has  not  been  accepted  by  the  majority 
of  clinicians.  Definite  etiologic  proof  has  never  been  established  and  many 
arguments,  among  them  the  immunity  acquired  after  a  single  attack  has 
been  urged  against  it. 

The  plea  that  the  streptococcus  is  not  found  in  very  recent  cases  does 
not  always  hold.  In  a  fulminant  case,  seen  by  the  writer,  which  terminated 
fatally  in  sixteen  hours,  the  apparently  little  changed  tonsils  were  found 
to  be  internally  necrotic  and  crowded  with  streptococci.  Most  authors 
unequivocally  agree,  that  the  course  of  the  disease  and  its  complications 
are  largely  governed  by  this  streptococcic  infection.  True,  a  number  of 
observers  have  found  that  cases  both  with  and  without  complications  have 
an  equal  number  of  streptococci  in  the  blood. 

The  studies  of  Bliss  and  Tunnicliff  have  shown,  that  the  streptococcus 
hemolyticus  isolated  from  the  throats  of  patients  in  the  acute  stage  of 
scarlet  fever  forms  a  distinct  biologic  group  apparently  peculiar  to  this 
disease.  An  immune  serum  produced  with  such  hemolytic  streptococci, 
protected  mice  against  cultures  isolated  from  scarlet  fever  patients,  but 
not  against  hemolytic  streptococci  from  other  sources  such  as  erysipelas, 
otitis  media  and  influenza.  Similiar  results  have  been  obtained  by  means 
of  agglutination  tests. 

Mode  of  Infection. — Scarlet  'fever  very  often  spreads  from  the  ill  to  the 
well.  It  is  usually  contagious  at  the  onset  and,  in  a  measure,  even  a  few 
days  before  the  onset  of  the  disease.  It  is  quite  certain,  that  the  contagious 
principle  exists  from  the  first  day  of  the  manifestations  of  the  disease  and 
with  gradually  decreasing  activity  persists  for  some  weeks.  Transmission 
is  especially  frequent  from  light,  ambulant,  arid  often  unrecognized  cases, 
in  which,  sometimes,  an  angina  without  exanthem  appears.  It  is  usually 
a  matter  of  contact  infection,  unless  the  patient  coughs  directly  in  the  face 
of  the  exposed  child.  We  do  not  know  whether  the  contagium  is  to  be  traced 
to  the  particles  of  the  skin  or,  as  seems  the  more  probable,  is  carried  by  the 
secretions  of  the  mouth,  by  the  pus  of  an  otitis  media,  or  by  the  desqua- 
mated skin  itself  infected  from  these  sources.  Children  vaccinated  by  the 
subcutaneous  injection  of  the  mouth  secretions  of  fresh  cases  have  devel- 
oped scarlet  fever,  which  tends  to  show  that  these  secretions,  at  least  dur- 
ing the  earlier  stages  of  the  disease,  contain  the  infective  organism.  The 
long  duration  of  the  contagious  period  is  clearly  shown  by  the  fact,  that 
after  full  recovery,  completed  desquamation,  and  careful  disinfection  the 
discharged  patient  may.  nevertheless,  infect  newly-exposed  or  previously 
absent  members  of  the  family.  Not  infrequently,  transmission  takes  place 
through  the  medium  of  healthy  people,  utensils,  articles  of  clothing,  etc., 
upon  which  the  virus  may  remain  active  for  several  months  or  even  for 
a  year  or  two.  In  sporadic  cases  the  source  of  the  infection  may  hardly 
ever  be  traced,  but  during  epidemics  a  direct  and  apparent  contagion 
is  more  common. 


THE  ACUTE  INFECTIOUS  DISEASES  581 

The  port  of  entry  of  the  virus  cannot  be  definitely  established  as  long  as 
the  organism  itself  is  unknown.  Numerous  observations,  however,  appear 
to  indicate,  that  entry  is  usually  effected  in  the  pharynx.  This  view  is 
apparently  sustained  by  cases  in  which  scarlet  fever  has  developed  through 
wounds,  when  angina,  in  other  instances  always  present,  is  absent.  In  this 
event  a  dirty  discharge  issues  from  the  wound  and  the  exanthem  begins  on 
the  neighboring  surface;  suggesting  that  in  such  exceptional  cases  the  infec- 
tive agent  penetrates  the  skin  at  the  point  of  injury — a  result  observed  in  a 
tracheotomy  wound,  a  scratched  chicken-pox  pustule,  etc.  Cases  of  alleged 
scarlet  fever  after  burns  must  be  considered  in  the  author's  judgment,  as 
in  part  at  least,  toxic  erythemata. 

The  Incubation  Period . — -This  period  usually  covers  from  three  to  five 
days.  In  some  instances,  and  particularly  in  scarlet  fever  originating  in 
wounds,  the  incubation  may  not  exceed  twenty-four  hours. 

Children  between  the  ages  of  three  and  six  years  are  most  frequently 
affected.  A  few  cases  are  seen  in  the  second  half  of  infancy.  It  is  very  rare 
from  the  third  to  the  sixth  month.  It  is  very  exceptional  in  the  new-born 
and  probably  occurs  only  when  the  mother  has  the  disease.  Cases  reported, 
sometimes  with  comparative  frequency  in  the  new-born,  (see  Tables,  page 
573),  are  probably  confused  with  a  severe  grade  of  erythema  neonatorum. 
The  disease  is  not  uncommon  up  to  the  twentieth,  or  even  the  thirtieth 
year,  after  which  its  tendency  is  to  entire  disappearance.  One  attack  con- 
fers very  lasting  immunity,  although  second  attacks  are  by  no  means  very 
rare  and  are  certainly  of  more  common  occurrence  than  in  measles. 

Predisposition  is  generally  less  marked  than  in  measles  or  pertussis,  so 
that  only  a  moderate  percentage  of  exposed  and  non-immunized  persons 
take  the  disease.  This  percentage,  in  fact,  does  not  exceed  twenty  even  in 
serious  epidemics.  In  large  families,  even  without  a  resort  to  prophylactic 
measures,  only  a  single  case  may  occur;  while  in  measles,  and  usually  in 
pertussis,  all  those  who  have  not  had  the  disease  commonly  contract  it. 

One  peculiarity  of  scarlet  fever  lies  in  the  fact,  that  the  disease  may 
occur  sporadically  for  many  years,  with  occasional  increase  in  the  number 
of  cases,  but  without  its  entire  disappearance  at  any  time.  Furthermore, 
it  occurs  in  large  epidemics  at  very  irregular  intervals  of  from  five  to  ten 
years.  These  epidemics  grow  slowly  and  disappear  as  gradually,  without 
at  any  time  reaching  such  great  proportions  as  do  the  epidemics  of  measles. 
(See  curve  on  page  600.)  Another  peculiar  characteristic  of  scarlet  fever 
is,  that  the  disease  may  be  extraordinarily  benign  for  years  or  ^ven  decades 
and  then  suddenly  and  inexplicably  assume  a  frightful  and  fatal  virulence. 

Scarlet  fever  is  found  throughout  Europe  and  North  America,  but  seems 
to  be  uncommon  in  the  Far  East. 

Pathologic  Anatomy. — Even  though  the  angina  of  scarlet  fever  often 
superficially  resembles  diphtheria,  the  disease  process  is  of  a  much  more 
phlegmonous  type,  is  more  penetrative,  and  shows  a  greater  tendency  to 
purulent  degeneration  than  does  the  diphtheritic  form.  With  this  more 
severe  angina  an  inflammatory  necrosis  of  the  affected  tissue  develops,  with 
a  diffuse  superficial  and  deep  exudate  of  the  mucous  membrane,  which  soon 


582  TEXT-BOOK  OF  PEDIATRICS 

becomes  filled  with  streptococci.  This  so-called  coagulation  necrosis  very 
frequently  penetrates  deeply  and  not  only  destroys  the  visible  pharyngeal 
structures  but  also  infects  the  regional  nodes,  which  suffer  in  part  a  puru- 
lent degeneration.  The  streptococci  may  also  cause  a  purulent  phlegmon 
in  the  mediastinum,  in  the  middle  ear,  or  in  certain  joints,  due  in  part  to 
the  spread  of  the  virus  of  the  scarlet  fever  and  in  part  to  an  independent 
production  of  sepsis.  At  autopsy,  in  persons  dying  of  scarlet  fever,  an  hy- 
perplasia  of  the  entire  lymphoid  tissue  is  frequently  found. 

Scarlet  fever  presents  so  extremely  invariable  a  picture  of  symptoms 
that  it  is  quite  impossible  to  formulate  a  description,  that  will  apply  to  all 
cases.  To  make  the  matter  clearer  it  seems  best  to  describe,  first,  some 
average  forms  of  moderate  intensity  and  then  to  detail  the  numerous  varia- 
tions and  complications,  which  present  themselves. 

The  Usual  Disease-picture. — -After  an  incubation  period  of  from  three 
to  five  days,  during  which  there  are  no  symptoms,  the  onset  occurs  suddenly 
with  vomiting,  high  fever,  and  so  severe  a  disturbance  of  the  child's  general 
health,  that  he  goes  to  bed  voluntarily.  Older  children  complain  of  head- 
ache and  sore  throat  and  younger  ones  appear  apathetic,  restless,  and  may 
be  delirious.  Occasionally  convulsions  occur. 

The  thermometer  registers  a  temperature  of  39°- 41°  C.  (102°-104°  F.). 
No  organic  lesion  is  demonstrable.  The  throat  shows  a  marked  injection, 
often  sharply  circumscribed  at  the  hard  palate.  The  submaxillary  lymph 
nodes  are  slightly  enlarged  and  painful  and  the  inguinal  nodes  also  may  be 
affected.  Even  though  the  intense  reddening  of  the  throat  may  arouse 
suspicion  of  scarlet  fever  in  the  mind  of  the  experienced  observer,  the  diag- 
nosis cannot  be  definitely  made  until  the  rash  appears. 

The  eruption  usually  develops  in  from  twelve  to  twenty-four  hours  after 
the  onset  of  symptoms.  It  usually  appears  first  on  the  neck,  the  breast  or 
the  back,  but  in  exceptional  cases  it  may  be  first  seen  on  the  extremities. 
It  spreads  rapidly  to  the  entire  body,  commonly  extending  to  the  thighs 
ard  the  arms  and  then  to  the  forearm  and  hands  and  to  the  legs  and  feet. 
In  the  course  of  about  two  days  the  rash  is  fully  developed  and  covers  the 
entire  body  with  the  exception  of  the  face,  which  usually  shows  but  a  con- 
gestive reddening  of  the  cheeks.  The  nose,  upper  lip  and  chin  remain 
entirely  clear.  This  pale  triangle  of  which  the  chin  forms  the  base,  stands 
in  vivid  contrast  to  the  bright  red  skin  of  the  rest  of  the  body  and  forms  a 
characteristic  feature  of  scarlet  fever. 

The  rash  consists,  at.  first,  of  very  small,  discrete  bright  red  spots, 
between  which  normal  skin  is  still  discernible.  Successive  crops  of  spots 
become  distributed  between  those  of  first  appearance,  so  that  in  one  or 
two  days  a  confluent  exanthem  is  produced,  which  takes  on  a  brighter  and 
brighter  hue.  The  initial  form  of  the  small  spots  can  be  made  out  in  but  a 
few  places,  as  the  inner  surface  of  the  thigh  and  the  back  of  the  hands.  The 
rash  disappears  completely  upon  pressure,  and  upon  its  removal  the  indi- 
vidual red  spots  return  first  but  are  immediately  followed  by  the  reddening 
of  the  entire  skin. 


THE  ACUTE  INFECTIOUS  DISEASES 


583 


After  the  eruption  has  existed  for  a  short  time  the  skin  from  which 
the  redness  is  removed  by  pressure  appears  yellowish.  This  is  especially 
observed  in  the  skin  of  the  abdomen.  As  a  whole,  the  skin  is  somewhat 


FIG.  148. — Exanthem  of  scarlet  fever  on  the  shoulder,  in  part  as  scarlatina  miliaris.    From 
wax  model  (Dr.  Henning)  in  the  Vienna  Children's  Hospital,  Prof,  von  Pirquet. 


swollen.  With  the  continued  spread  of  the  exanthem  and  with  the  constant 
appearance  of  new  spots  the  bright  red  eruption  becomes  darker  and  darker, 
so  that  the  patient's  skin  finally  appears  almost  purple. 

Each  individual  spot  is  initially  a  bright  red,  smooth,  rounded  area 
hardly  a  millimeter  in  diameter.  As  it  develops,  this  spot  becomes  slightly 
raised,  so  that  in  a  cross-light  the  skin  has  the  appearance  of  fine-grained 


584 


TEXT-BOOK  OF  PEDIATRICS 


leather  and  feels  rough  to  the  touch.  This  follicular  swelling  is  especially 
prominent  over  the  back  of  the  hands  and  feet,  the  forearm  and  legs,  since 
the  eruption  is  more  elevated  here  than  in  other  parts.  At  times  the  spots 
become  slightly  vesicular,  with  a  cloudy  whitish  content,  the  vesicles  des- 
quamating early  at  their  apices.  This  form  is  known  as  scarlatina  miliaris, 
but  is  an  eruptive  variation  without  any  serious  significance.  The  forma- 
tion, however,  of  unusually  large  elevated  spots  is  rather  indicative  of  a 
severe  type  of  the  disease.  Occasionally  very  small  hemorrhages  appear 
over  the  flexor  surfaces  of  the  elbows,  in  the  axillae,  or  in  other  parts  where 
the  skin  is  rubbed  or  scratched  by  the  clothing.  By  applying  a  tourniquet 
above  the  elbow  for  a  few  minutes  petechial  hemorrhages  will  invariably 
occur  below  the  joint  within  a  short  time  (Rumpel-Leede).  If  the  skin 
is  scratched  with  the  finger-nails  a  white  line  appears  as  the  result  of  a 


Fia.  149. — Typical  curve  of  scarlet  fever.     Six-year-old  girl. 

vasomotor  spasm   (raie  blanche).      The  eruption  often    causes    annoying 
itching  and  children  will  scratch. 

The  exanthem  usually  reaches  its  height  in  from  three  to  five  days.  It 
gradually  fades  in  the  same  order  in  which  it  appears.  By  the  fourth  to 
the  seventh  day,  or  by  the  beginning  of  the  second  week,  the  rash  has 
usually  disappeared  entirely,  often  leaving  a  little  roughness  and  slightly 
increased  pigmentation  At  this  stage  desquamalion  of  the  skin  commences. 
It  may  begin,  and  often  does,  before  the  rash  has  entirely  disappeared  but, 
as  a  rule  the  scaling  begins  during  the  second  week  or  even  later.  It  is 
first  seen  over  those  parts  of  the  body,  as  the  neck  and  axilla,  where  the 
skin  is  the  thinnest.  Upon  the  face  the  detritus  consists  of  extremely  fine 
scales.  In  other  parts  small  circular  areas  of  epidermis  are  sloughed  and 
the  entire  skin  is  then  shed  in  small  pieces  (see  Fig.  151).  The  more  severe 
the  eruption,  the  earlier  does  desquamation  occur.  The  skin  sloughs  are 
largest  where  the  skin  is  thickest.  Thus  the  largest  pieces  separate  from 
the  palms  of  the  hands  and  the  soles  of  the  feet,  where  desquamation  is 
long  postponed,  often  until  the  sixth  to  the  eighth  week  from  the  onset  of 
the  disease.  Usually  the  growth  of  the  finger-nails  is  impaired,  particu- 
larly on  the  thumb.  A  ridge  or  groove  is  formed  at  the  root  of  the  nail. 
This  occurs  at  the  outbreak  of  the  disease,  but  the  deformity  appears  from 
beneath  the  skin-fold  after  some  six  weeks  and  grows  outward  to  the  end 


THE  ACUTE  INFECTIOUS  DISEASES  585 

of  the  sixth  month.    Similar  changes  of  the  nails  are  seen  in  many  other 
acute  diseases,  but  never  so  distinctly  as  they  are  in  scarlet  fever. 

The  month  and  the  throat  also  present  characteristic  symptoms.  A 
redness  and  swelling  of  the  tonsils,  the  soft  palate,  and  the  pharynx,  which 
appear  on  the  first  day,  become  more  marked  during  succeeding  days  and 
cause  more  or  less  difficulty  in  swallowing,  and  the  consequent  refusal  of 
food.  Children  of  sufficiently  advanced  years  complain  of  sore  throat. 
The  regional  mucous  membranes  show  a  bright  flaming  red,  of  a  degree  of 
color  hardly  ever  seen  in  simple  angina.  The  swollen  tonsils  often  meet  in 
the  median  line  and  yellow  masses  protrude  from  the  lacunae.  The  sub- 
maxillary  nodes  are  enlarged  and  painful.  The  angina  reaches  its  height 


FIG.  150. — Scarlet  fever  tongue  (strawberry),  marked  swel- 
ling of  the  papillse. 

in  three  to  five  days,  after  which  it  gradually  subsides.  Just  at  this  point 
a  dreaded  necrotic  angina  is  apt  to  develop  (see  below). 

During  the  first  few  days  the  tongue  is  heavily  coated,  but  soon  it 
becomes  clean  and  on  the  third  or  fourth  day  shows  a  clean,  bright  red  sur- 
face upon  which  its  markedly  enlarged  papillse  stand  out  distinctly,  giving 
the  so-called  strawberry  tongue.  This  characteristic  feature,  however, 
may  be  absent. 

The  fever  during  the  first  three  to  five  days  runs  persistently  between 
39°-40°  C.  (102°-104°  F.),  or  even  higher.  It  does  not  show  any  marked 
remissions  and  with  the  full  development  of  the  exanthem  may  go  even 
higher.  The  intensity  of  the  fever  is  dependent  more  upon  the  severity  of 
the  angina  than  it  is  upon  the  severity  of  the  skin  eruption.  A  lytic,  step- 
by-step  fall  of  the  temperature  occurs,  the  normal  point  being  reached  by 


586 


TEXT-BOOK  OF  PEDIATRICS 


the  end  of  the  first  or  the  beginning  of  the  second  week,  as  a  rule,  in  uncom- 
plicated cases  (see  Figure  149).  Not  infrequently,  however,  an  unex- 
plained fever  may  continue  during  the  entire  second  week  and  after  the 
rash  has  disappeared,  without  any  evident  cause  or  complication  (Fig.  152). 
The  pulse  is  markedly  increased  from  the  onset  of  the  disease  and,  in 
children,  to  a  rate  that  is  hyper-proportional  to  the  rise  of  temperature. 
In  young  patients  with  a  temperature  of  40°  C.  (104°  F.),  the  pulse  is  often 

160  to  180  a  minute  without  giving  any 
cause  for  anxiety.  An  increased  frequency 
is  sometimes  noted  even  in  cases  without 
fever. 

The  patient's  general  well-being  is  often 
profoundly  affected.  Apathy  or  restlessness, 
insomnia,  anorexia,  and  weakness  are  usual 
manifestations.  Vomiting  often  occurs  even 
after  the  first  day  or  two. 

The  disease  involves  the  respiratory 
tract  slightly,  if  at  all,  and  does  not  affect 
the  ears  or  the  conjunctiva.  A  moderate 
degree  of  congestion  of  the  nasal  mucosa 
may  cause  some  difficulty  in  breathing,  but 
is  accompanied  by  very  little  secretion. 

Aside  from  the  increased  frequency  of 
the  pulse-rate  and  an  occasional  slight  sys- 
tolic murmur,  the  heart  gives  no  special 
indication  of  disturbance  during  the  fever. 
The  blood  frequently  shows  a  neutro- 
philic  leucocytosis  which  does  not  disap- 
pear until  the  second  or  third  week.  At 
times  there  is  an  increase  also  of  the  eosino- 
philes,  discoverable  at  the  end  of  the  first 
week,  but,  according  to  our  observations, 
often  lacking.  The  leucocytes  of  recent 
cases  attended  with  high  fever  often  con- 
tain certain  inclusions  (Dohle).  These  are 
frequent,  however,  in  other  infectious  diseases,  such  as  lobar  pneumonia. 
Enlargement  of  the  lymph  nodes  of  the  submaxillary  region  may  be 
quite  marked  and  may  make  movements  of  the  head  painful.  Other  super- 
ficial nodes,  among  them  the  cervical,  inguinal  and  axillary  groups,  are 
also  distinctly  involved.  The  liver  and  the  spleen  are  occasionally  distinctly 
enlarged.  The  urine,  during  the  course  of  the  fever,  is  cloudy,  scanty,  and 
concentrated.  Often  it  contains  some  albumen,  casts,  and  red  blood-cells, 
but  it  clears  up  with  the  fall  of  the  fever  if  a  secondary  nephritis,  which  is 
so  common  a  complication,  does  not  ensue.  Its  reddish  color  is  due  to  the 
presence  of  a  quantity  of  urobilin,  which  is  a  characteristic  of  scarlet  fever. 
Acetonuria  is  often  present. 


FIG.  151 . — Five-year-old  girl  on  the  four- 
teenth day  of  scarlet  fever.  Bilateral 
phlegmon  of  the  cervical  lymph  nodes  and 
marked  desquamation  on  the  trunk  and 
arms. 


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IIIIIIIIIIIUIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII 


588  TEXT -BOOK  OF  PEDIATRICS 

With  the  decline  of  the  fever  these  various  symptoms  disappear.  By  the 
middle  or  end  of  the  second  week  the  patient  is  fully  convalescent.  In 
fact,  it  is  often  difficult  to  keep  him  in  bed  and  away  from  other  children 
until  desquamatiori  is  complete. 

PECULIARITIES,  SEQUELAE  AND  COMPLICATIONS  OF  SCARLET  FEVER 

The  description  given  serves  for  a  mild  typical  form  of  scarlet  fever  as 
it  may  be  seen  in  a  majority  of  cases.  Variations  in  form  of  even  mild 
attacks,  but  particularly  in  those  inclining  to  a  greater  degree  of  severity, 
are  so  extremely  common  among  sporadic  cases  as  well  as  in  epidemic  out- 
breaks, that  it  hardly  seems  proper  to  attempt  a  classical  description.  Nor 
is  it  correct  to  call  the  numerous  disturbances,  which  so  continually  appear 
at  the  close  of  the  fever  period,  such  as  phlegmon  or  scarlatinal  nephritis, 
etc.,  complications  of  the  disease,  since  they  are  as  apt  to  follow  the  mildest, 
as  they  are  the  most  fulminant  types.  It  is  better,  indeed,  to  term  them 
sequelae,  since  they  make  their  appearance  within  a  definite  period  of  three 
to  six  weeks  and  are  produced  by  the  virus  of  the  scarlet  fever  itself. 

The  mildest  expressions  of  the  malady  are  so  common  and  so  prevalent, 
tnat  Sydenham  and  Bretonneau  felt,  at  one  time,  that  they  could  scarcely 
call  scarlet  fever  a  disease;  while  later  they  were  convinced  by  hard  experi- 
ence, that  scarlatina  may  be  one  of  the  severest  afflictions  of  mankind. 
Frequently  the  angina,  the  fever,  and  the  malaise  are  so  insignificant,  that 
the  sick  child's  parents  become  aware  of  his  definite  illness  only  through 
the  appearance  of  the  skin  eruption.  Indeed,  the  whole  course  of  the 
disease  may  be  so  mild,  that  it  is  entirely  overlooked  until  the  ensuing  des- 
quamation  or  the  development  of  nephritis  calls  attention  to  the  fact,  that 
the  child  has  had  scarlet  fever.  The  angina  may  be  so  very  slight,  the  fever 
never  exceeding  38°  C.  (100°  F.),  and  the  eruption  so  trivial,  that  a  diagnosis 
in  sporadic  cases  is  often  impossible.  The  author  is  quite  positive,  that  he 
has  seen  such  a  case  in  a  family  the  other  members  of  which  had  more  seri- 
ous types  of  the  disease.  On  the  other  hand,  rudimentary  forms  are  seen 
in  which,  though  the  eruption  is  extremely  transient  or  wholly  lacking, 
other  symptoms  are  very  distinct.  When  but  slightly  developed  the  rash 
is  usually  most  clearly  visible  upon  the  back.  In  rare  instances  the  appear- 
ance of  the  eruption  is  delayed  until  the  third  to  the  fifth  day  after  the 
onset  of  the  disease.  Cases  occur  without  eruption  (scarlatina  sine  erup- 
tione),  chiefly  among  older  children  or  adults;  and  naturally  these  are 
readily  mistaken  for  angina  or  diphtheria  if  the  development  of  unequi- 
vocal forms  of  the  disease  in  other  members  of  the  family  does  not  assist 
the  diagnosis. 

In  sporadic  cases  of  the  fulminant  type  the  erupted  spots  are  usually 
large.  In  rare  instances,  during  convalescence,  the  skin  tends  to  a  pecul- 
iar local  reddening  and  to  a  necrosis,  resulting  from  traumatic  irritation 
(erythema  post-scarlatinosum,  Schick'). 

The  severe  toxic  type  of  the  disease  stands  in  sharp  contrast  to  the  mild 
and  easily  overlooked  forms.  The  child  suddenly  becomes  ill,  with  high 


THE  ACUTE  INFECTIOUS  DISEASES  589 

fever,  vomiting,  convulsions  and  delirium,  which  may  pass  into  complete 
unconsciousness.  The  respiration  is  deep  and  toxic,  the  pulse  extremely 
rapid  and  hardly  palpable.  The  lips  and  skin  are  cyanotic,  the  hands  and 
feet  cold,  despite  the  high  fever.  The  throat  is  swollen  and  red  and  the 
skin  is  mottled  or  shows  large  blue  spots,  but  no  scarlatinal  eruption. 
Death  may  result,  sometimes  in  one  or  two  days,  more  frequently  in  from 
three  to  five  days. 

In  cases  which  are  not  so  rapidly  fatal,  a  more  severe  angina  and  a  more 
marked  inflammation  of  the  lymph  nodes  of  the  neck  develop.  A  distinct 
eruption,  sometimes  visible  in  only  limited  areas,  may  appear  a  day  or 
two  before  death.  Excepting  in  an  epidemic,  such  fulminant  cases  are 
very  rare,  but  they  may  be  met  with  now  and  then  in  families  in  which 
other  children  are  suffering  from  milder  forms.  According  to  Czerny,  this 
fulminant  form  occurs  chiefly  in  children  of  exudative  diathesis. 

Again,  we  see  cases  of  violent  onset  with  high  fever,  severe  malaise, 
marked  angina,  in  which,  nevertheless,  all  symptoms  disappear  after  five 
or  six  days,  when  the  disease  goes  on  to  a  favorable  termination.  Some- 
times, in  such  cases  the  picture  of  a  simple  or  lacunar  angina  is  replaced 
by  that  of  necrotic  angina,  or  diphtheroid  scarlet  fever.  The  surface  of  the 
tonsil  is  partially  or  entirely  covered  by  a  whitish  exudate,  which  may  seem, 
at  first,  very  thick  and  may  have  a  membranous  character  closely  resem- 
bling true  diphtheria.  Soon,  and  sometimes  from  the  onset  of  the  disease, 
this  exudate  becomes  more  deeply  imbedded  in  the  mucous  membrane; 
it  has  a  pasty  appearance  and  can  be  removed  by  scraping  in  large  pieces, 
as  in  a  case  of  diphtheria.  It  is  less  fibrinous,  however.  Frequently  the 
infiltration  spreads  to  the  anterior  palatine  arch.  Seldom  it  spreads  to  the 
posterior  wall.  Coincidently  with  this  more  or  less  diffuse  necrosis  of  the 
mucous  membrane,  appears  a  swelling  of  the  lymph  nodes  of  the  neck. 
The  inflammation  often  spreads  to  the  peri-nodal  tissues.  Movement  of 
the  head  becomes  extremely  painful  and  is  avoided  by  the  patient.  When 
the  phlegmon  in  the  region  of  the  submaxillary  gland  is  hard  and  tense 
and  spreads  to  such  an  extent  that  the  bilateral  swelling  meets  beneath 
the  chin,  the  condition  is  serious. 

Necrotic  angina  frequently  spreads  to  the  nasopharynx  or  may  origi- 
nate there.  The  median  raphe  of  the  soft  palate  is  then  seen,  from  behind, 
to  be  white  and  infiltrated;  nasal  breathing  becomes  difficult  and  as  a  result 
of  the  invasion  of  the  nares  an  irritating  seropurulent  excretion  flows  from 
the  nose  and  produces  small  sores  upon  the  upper  lip.  The  lips  are  often 
so  badly  fissured  that  opening  of  the  mouth  causes  severe  pain.  The  buccal 
mucosa  is  markedly  reddened  and  a  dirty  whitish  deposit,  easily  removed, 
is  seen  along  the  edges  of  the  gums.  A  case  of  this  kind  may  be  considered 
relatively  favorable  if  the  necrosis  does  not  exceed  the  limits  we  have  de-. 
scribed.  Within  five  to  eight  days  the  necrosed  tissues  may  slough  without 
any  more  serious  injury.  But  in  severe  cases  the  necrosis  goes  deeper  and 
in  a  few  days  the  tissue  of  the  tonsils  becomes  a  discolored  brownish  mass. 
The  destruction  may  extend,  also,  to  the  pharyngeal  arches,  the  uvulas 
and  the  pharynx.  An  excessive  muco-  sanguine-purulent  secretion  cover, 


590  TEXT-BOOK  OF  PEDIATRICS 

the  invaded  area  and  prevents  closer  inspection.  The  necrosis  may  even 
spread  to  the  epiglottis  and  to  the  false  and  true  vocal  chords,  causing 
hoarseness  and  stenosis  of  the  larynx. 

This  deep  necrosis  is  certainly  due  to  a  streptococcic  invasion.  The 
streptococci  may  be  found  massed  in  the  pseudomembranous  exudate  of 
the  condition.  The  same  infection  may  cause  a  dry  necrosis  of  the  lymph 
nodes  of  the  neck,  especially  in  the  sublingual  and  cervical  groups.  From 
the  neck,  the  infection  may  spread  to  the  mediastinum  causing  a  purulent 
mediastinitis,  which  may  involve  the  trachea  and  may  even  produce  general 
sepsis  and  metastatic  abscesses  in  the  various  larger  joints,  in  the  perito- 
neum, or  in  the  pleura  etc. 

If  the  necrotic  angina  involves  a  large  area,  it  may  be  a  direct  cause  of 
death,  fatal  termination  ensuing  from  general  exhaustion,  in  from  a  few 
days  to  three  weeks  time,  as  a  result  of  sepsis.  It  may  be  fairly  said,  that 
the  presence  or  absence  of  angina  determines  the  outcome  of  the  disease 
and.  indicates  the  severity  of  the  epidemic  during  which  the  case  occurs. 

The  ear  is  very  frequently  affected  in  the  course  of  the  disease,  even 
with  a  simple  angina,  but  an  otitis  media  is  especially  associated  with 
diphtheroid  infection  of  the  nasopharynx.  Purulent  otitis  media  usually 
makes  its  appearance  by  the  middle  or  end  of  the  first  week,  but  occasionally 
develops  much  later.  It  usually  destroys  the  entire  tympanic  membrane 
after  but  a  very  short  period  of  pain,  followed  by  a  purulent  discharge. 
The  otitis  of  scarlet  fever  is  peculiar  in  that  it  readily  causes  necrosis  of 
the  auditory  ossicles  and  infection  of  the  mastoid.  It  may  result  in  per- 
manent disturbances  of  hearing  or  in  complete  deafness.  Mastoiditis  and 
septic  sinus  thrombosis  are  not  uncommon  sequelae.  The  great  majority 
of  cases,  however,  terminates  quite  favorably. 

Necrotic  angina  occurs  not  only  in  cases  that  are  initially  severe,  but 
also  in  those  that  during  the  first  four  or  five  days  are  apparently  mild. 
The  temperature  even  begins  to  fall,  but  the  lysis  stops  at  the  end  of  the 
first  or  the  beginning  of  the  second  week  and  the  temperature  rises  again 
without,  for  the  time  being,  any  apparent  reason.  At  this  period  it  may 
be  understood  that  any  new  rise  of  temperature  indicates  a  new  localiza- 
tion of  infection  or  a  new  complication.  Frequently  it  is  the  evidence  of 
necrotic  angina,  of  otitis,  or  severe  lymphadenitis  (Fig.  151).  On  this 
account  a  careful  notation  of  the  temperature  curve  is  important.  There 
are  cases  in  which  a  diphtheroid  angina  precedes  the  eruption.  These  are 
easily  mistaken  for  true  diphtheria  and  are  erroneously  isolated  in  the 
diphtheria  ward.  Older  and  stronger  children  recover  from  the  severe 
forms  of  necrotic  angina  and  its  sequelae  and  even  deep  ulcers  and  exten- 
sive loss  of  substance  may  heal,  but  the  general  health  of  the  patient 
is  always  profoundly  affected.  Very  frequently  however,  consequent  sep- 
tic processes  will  cause  death  weeks  later,  despite  the  fact  that  the  angina 
may  have  healed. 

The  respiratory  organs  as  a  general  thing,  are  but  slightly  affected. 
In  severe  cases,  respiration  is  often  embarrassed  on  account  of  the  closure 
of  the  nares  or  the  stenosis  of  the  larynx,  incident  either  to  the  severe  inflam- 


THE  ACUTE  INFECTIOUS  DISEASES 


591 


ation  of  the  mucosa  or  to  the  pressure  arising  from  involvement  of  the 
mediastinum.  In  some  instances  the  hoarseness  and  stenosis  are  so  aggra- 
vated as  to  suggest  interference.  Rarely,  however,  is  the  stenosis  sufficient 
to  justify  this  and  hardly  ever  does  the  procedure  prolong  life. 

Purulent  bronchitis  and  broncho-pneumonia  are  not  uncommon  com- 
plications, nor  is  an  exudative  pleuritus 
which  always  becomes  purulent  and  some- 
times is  associated  with  a  purulent  peri- 
carditis. 

Occasionally  the  conjunctivas  are  as 
markedly  affected  as  in  measles. 

Scarlatinal  rheumatism  is  the  term 
applied  to  the  painful  swelling  of  indi- 
vidual joints,  which  may  appear  at  the 
end  of  the  first  or  during  the  second 
week  of  the  disease.  It  occurs  particu- 
larly in  the  hands,  fingers,  knees  and  feet 
and  its  course  is  attended  by  an  increase 
of  temperature.  The  swelling  is  often 
slight  and  without  any  redness.  This 
affection  should  not  be  confused  with 
pyemic  disease  of  the  joints.  It  always 
disappears  within  a  short  time. 

The  heart  is  frequently  involved.  Even 
the  unusually  rapid  heart-beat  common 
in  scarlet  fever  shows  that  the  toxins  of 
the  disease  have  a  special  affinity  for  the 
heart.  In  severe  cases  the  increased  heart 
action  may  persist  for  weeks  after  the 
fever  has  disappeared.  It  is  associated  at 
times,  with  signs  of  cardiac  weakness. 
Actual  disease  of  the  heart  is  quite  com- 
mon even  at  the  beginning  of  the  attack. 
It  has  been  especially  studied  by  Schick. 
Even  in  mild,  benign,  cases  it  is  often  pos- 
sible to  demonstrate,  at  the  end  of  the 
first  or  in  the  course  of  the  second  week, 
impure  heart  sounds  at  the  apex  with 
bradycardia  and  enlargement  of  the  heart 
to  the  left  (Fig.  154).  Added  to  these 
findings,  a  systolic  murmur  is  frequently 
heard  in  the  pulmonic  and  apical  areas. 

All  these  phenomena,  lasting  for  several  weeks  may  eventually  disappear. 
It  is  probable  that  no  myocardial  changes  are  present  in  these  mild  forms, 
but  that  merely  an  atony  of  the  heart  exists,  often  associated,  according 
to  Sederer  and  Stolte,  with  loss  of  body-weight  It  is  not  to  be  forgotten, 
however,  that  in  the  course  of  scarlet  fever  endocarditis  may  develop 


592  TEXT-BOOK  OF  PEDIATRICS 

very  insidiously  during  the  fever  period  at  the  onset  of  the  disease  and 
that  it  may  lead  to  permanent  valvular  lesions  and  particularly  to  mitral 
insufficiency.  Pericarditis,  as  a  complication  of  scarlet  fever,  is  less  common. 

THE  GASTRO-INTESTINAL  TRACT. — In  severe  cases  appetite  entirely  fails 
even  when  there  is  no  difficulty  in  swallowing.  Excessive  diarrhoea  is  often 
a  sign  of  sepsis. 

Commonly  the  nervous  system  is  but  slightly  affected.  Somnolence 
and  delirium  may  appear  in  case  of  severe  infection  with  uremia.  Maniacal 
and  depressive  conditions  may  appear  temporarily  during  convalescence. 
True  meningitis  is  rare  and  is  usually  a  manifestation  of  general  sepsis, 
sinus  thrombosis,  etc. 

Fever  falls  by  lysis  only  in  uncomplicated  cases.  The  fall  of  temper- 
ature usually  sets  in  at  the  beginning  of  the  second  week,  but  even  in 
cases  without  particular  localization,  it  may  not  be  completed  before  the 
end  of  the  third  week.  Even  though  the  temperature  has  reached  the  nor- 
mal level  and  no  severe  throat  affection  or  other  complication  exists,  the 
disease  may  not  be  ended.  Sequelae  may  still  threaten. 

Irregular  rises  of  temperature,  which  are  always  a  subject  for  careful 
study,  may  appear  after  the  end  of  the  second  week  and  even  as  late  as  the 
sixth  week.  Very  often  no  reason  for  such  a  rise  can  be  found,  even  after 
most  careful  observation,  and  it  is  termed  a  relapsing  or  typhoidal  scarla- 
tina. Frequently,  however,  a  sequel  may  presently  appear  in  the  form  of 
a  renewed  swelling  of  the  cervical  lymph  nodes,  an  otitis  media,  an  endo- 
carditis or  occasionally  even  an  angina,  or  a  recrudescence  of  the  rash. 
Now  and  then,  one  has  to  deal  with  a  pseudo-relapse,  when  a  case  mistaken 
for  scarlet  fever  has  been  placed  in  an  isolation  ward  for  this  disease  and 
then  actually  acquires  it. 

Nephritis  is  the  most  important  and  the  most  common  sequel  of  scarlet 
fever.  Usually  it  appears  in  the  third  week  of  illness  or  at  the  earliest 
by  the  twelfth  day  but  it  may  develop  as  late  as  the  fourth  or  even  the 
sixth  week. 

Nephritis  is  often  heralded  by  fever,  vomiting  and  headache,  while 
again  attention  may  be  called  to  it  by  the  development  of  edema,  or  by  the 
discovery  of  blood  or  albumen  in  the  urine.  The  disease  in  itself,  is  always 
essentially  an  injury  to  the  vascular  structure  of  the  kidney,  a  glomerular 
nephritis,  by  which  the  excretion  of  water  is  especially  impaired.  The 
urine  is  almost  always  bloody;  at  times  it  contains  much  blood  and  is 
scanty.  The  greater  the  diminution  in  the  quantity  of  the  urine,  the  more 
serious  is  the  case.  The  amount  of  albumen  present,  up  to  one  per  cent., 
and  the  appearance  of  red  blood-cells  and  of  a  variety  of  casts,  are  of  less 
prognostic  importance.  The  course  of  this  complication  is  often  marked 
by  an  irregular  fever  (Fig.  155).  Frequently  a  marked  dropsy,  which  may 
involve  the  peritoneal,  pleural,  or  pericardial  cavities,  develops.  Cardiac 
dilatation,  accompanied  at  times,  by  bradycardia,  is  of  early  occurrence. 
Blood-pressure  is  increased.  Headache  and  vomiting  are  frequently  symp- 
toms and  often  occur  with  the  onset  of  uremia,  which  is  again  associated 
with  bradycardia,  and  may  lead  to  convulsions  •  and  amaurosis.  Death 


Fia.  155. — Scarlet  fever  with  nephritis  (15th  daj 


imphadenitis  colli  (21st  day).    Eight-year-old  girl. 


THE  ACUTE  INFECTIOUS  DISEASES  593 

may  result  from  uremia  and  dropsy  or  dilatation  of  the  heart.  In  most 
cases  recovery  from  nephritis  follows  in  from  four  to  six  weeks;  more  rarely 
it  may  be  a  matter  of  months.  Not  infrequently  it  runs  into  a  chronic 
form,  which  may  later  develop  into  a  contracted  kidney. 

The  frequency  of  nephritis  varies  greatly.  It  ranges  from  two  to 
thirty  per  cent,  of  all  cases,  depending  upon  the  conditions  of  the  individual 
attack  and  the  general  character  of  the  epidemic  in  which  it  occurs.  It  is 
not  always  the  severe  types  of  the  disease,  that  seem  to  show  a  peculiar 
tendency  to  it.  Nephritis,  indeed,  may  develop  after  the  very  mildest 
forms  and  even  in  cases,  which  have  escaped  observation.  For  a  more 
detailed  description  of  the  nephritis  of  scarlet  fever  the  reader  is  referred 
to  page  431. 

The  complication  of  scarlet  fever  with  diphtheria  deserves  special  con- 
sideration. Even  before  the  science  of  bacteriology  had  evolved,  careful 
observers  had  differentiated  a  diphtheroid  form  of  scarlatina,  without 
involvement  of  the  trachea  and  not  followed  by  paralysis,  from  true  diph- 
theria. The  membrane  in  the  former  instance,  despite  its  frequent  and 
very  close  resemblance  to  that  of  diphtheria,  does  not  show  the  Loffler 
bacillus.  In  the  smear  and  in  the  culture  chiefly  streptococci  are  found. 
Mixed  infections,  however,  are  not  uncommon.  When  the  two  diseases 
are  coincidently  epidemic  and  when  cases  are  not  properly  isolated,  per- 
haps, in  contagious  hospitals.  Clinical  differentiation  by  reliance  upon 
appearances  in  the  throat,  is  often  initially  impossible.  In  doubtful  and 
severe  cases,  and  in  the  absence  of  the  exanthem,  it  is  well  to  give  an 
injection  of  antitoxin  without  waiting  for  a  bacterial  diagnosis.  When 
diphtheria  develops  late  in  the  course  of  the  scarlatinal  infection,  after  the 
initial  throat  symptoms  have  disappeared,  it  is  more  easily  recognized. 

As  a  matter  of  fact  the  course  of  scarlet  fever  is  subject  to  numberless 
variations  and  recovery  is  prejudiced  by  unforeseen  focal  conditions, 
sequelse  and  complications.  Even  in  serious  cases  the  organism  often 
conquers  after  weeks  of  fever  and  relapse,  but  unfortunately  not  always 
without  permanent  injury.  The  most  frequent  irreparable  damage  is  that  to 
the  auditory  apparatus,  which  may  result  in  deafness.  Valvular  heart 
lesions  are  less  common  and  chronic  nephritis  is  most  rare. 

The  diagnosis  of  scarlet  fever,  in  advanced  cases,  is  readily  made  from 
the  skin  eruption,  the  fever,  the  characteristic  angina  and  the  strawberry 
tongue.  The  possibility  of  a  scarlatinal  origin  is  to  be  considered  in  even 
the  mildest  forms  of  angina  and  even  in  the  absence  of  the  exanthem. 
Much  greater  problems  present  themselves  to  the  physician  than  appear 
in  measles.  The  eruption  by  itself  may  never  be  considered  conclusive 
and  mistakes  are  especially  possible  in  the  absence  of  angina.  The  rash 
may  be  so  light  and  so  transient  and  so  atypical  as  to  serve  only  to  create 
doubt.  Lasting  for  only  a  few  hours  or  at  most,  a  day  it  is  commonly  not 
due  to  scarlet  fever.  "Scarlatina  sine  eruptione"  may  be  recognized  with 
certainty  only  in  the  presence  of  coincident  and  unmistakable  cases  or  when 
a  diphtheritic  exudate  appears  without  diphtheria  bacilli. 

The  greatest  and  often  quite  insurmountable  difficulties  are  presented 
38 


594  TEXT-BOOK  OF  PEDIATRICS 

by  those  infectious  and  toxic  erythemata,  common  among  children,  which 
resemble  scarlatina.  Particularly  the  fourth  or  Duke's  disease  produces 
an  eruption  very  similar  to  that  of  scarlet  fever,  without  exhibiting  any 
of  its  remaining  symptoms  which  in  scarlatina,  also,  of  mild  degree,  may 
be  absent. 

Ordinarily,  scarlet  fever  is  readily  distinguishable  from  measles  since 
it  lacks  the  prodromal  coryza  and  the  Koplik's  spots.  It  is  to  be  noted, 
however,  that  in  severe  cases  of  scarlatina  a  marked  conjunctivitis  may 
develop.  The  large  macular  eruption  characteristic  of  measles  is  never 
general  in  scarlet  fever,  although  it  is  found  in  small  areas  and  notably  on 
the  extremities.  Even  in  the  confluent  form  of  measles  some  areas  will 
always  be  found  in  which  the  eruption  is  characteristic.  In  rubella  the 
spots  are  always  discrete;  they  are  generally  larger  and  with  more  free 
spaces  between  them  than  in  scarlet  fever.  A  scarlatinoid  serum  exanthem 
may  present  considerable  difficulty  of  differentiation  but  it  usually  spreads 
from  the  point  of  injection;  it  is  not  associated  with  angina;  it  is  transient 
and  rapidly  changing  so  that  rubeolar  and  urticarial  eruptions  may  be  coin- 
cidently  or  alternately  present.  In  recrudescent  desquamative  scarlatinal 
erythema,  angina  also  is  lacking.  Moreover,  the  condition  is  characterized 
by  early  and  unusually  severe  desquamation  and  repeated  attacks.  It  is 
an  extremely  uncommon  disease. 

In  addition,  there  are  a  number  of  infectious  diseases  in  which  a  scarlat- 
inoid erythema  may  appear.  In  lobar  pneumonia,  typhoid  fever,  la 
grippe  or  influenza,  and  in  the  acute  disturbances  of  nutrition  of  infancy 
it  may  be  present.  A  similar  rash  results  sometimes  from  the  use  of  such 
medicinal  agents  as  quinine,  iodoform,  mercury,  atropin,  etc.  The  early 
eruption  of  chicken-pox  on  the  thighs  and  shoulders  may  resemble  that  of 
scarlet  fever.  The  redness  of  the  skin  in  crying  or  blushing,  now  and  then 
reminds  one  of  the  rash  of  scarlet  fever.  Occasionally  in  young  children, 
an  exanthem  of  miliaria  rubra,  caused  by  perspiration,  spreads  over  the 
entire  body.  It  may  be  distinguished  from  the  scarlatinal  rash  only  by  the 
fact,  that  the  eruption  is  raised  above  the  level  of  the  skin.  The  color  of 
the  skin  in  scarlet  fever,  as  seen  when  pressure  is  made  upon  the  eruptive 
surface  is  an  important  feature. 

As  may  be  inferred,  it  is  often  impossible  to  pass  upon  a  case  of  scarlet 
fever  from  the  eruption  alone.  A  smooth  diffuse  erythema  of  transient 
appearance  confined  to  small  areas,  pressure  upon  which  does  not  enable 
one  to  recognize  the  individual  maculae,  and  surrounded  by  a  coarse  urtic- 
arial eruption  is,  generally  speaking,  not  of  scarlatinal  origin.  Associated 
symptoms  and  especially  those  of  the  throat  and  tongue  must  always  be 
taken  into  consideration.  Even  the  blood  findings  may  aid  in  making  a 
differentiation.  Polynuclear  leucocytosis,  with  eosinophilia  is  indicative 
of  scarlet  fever.  Leucopenia,  with  a  reduction  of  the  polynuclear  cells  sug- 
gests a  serum  exanthem.  Quite  frequently,  however,  the  question  remains 
undecided  unless  other  neighborhood  cases  occur,  or  the  unrecognized 
attack  leads  to  desquamation  or  is  followed  by  nephritis.  The  develop- 
ment of  nephritis,  with  recurring  enlargement  of  the  cervical  nodes,  but 


THE  ACUTE  INFECTIOUS  DISEASES  595 

without  accompanying  angina  suggests  the  scarlatinal  cause  of  the  disease 
and  may  account  for  a  recent  unexplained  sore  throat. 

There  are  many  non-scarlatinal  erythemata  in  which  desquamation 
does  not  occur  or  is  very  slight.  If  it  appears,  it  is  always  earlier  and  more 
rapidly  concluded,  while  it  does  not  so  markedly  involve  the  hands  as  in 
scarlet  fever. 

The  prognosis  must  be  made  always  with  extreme  care,  since  it  is  impos- 
sible to  anticipate  surprises  even  in  mild  cases,  as  the  above  exposition  has 
made  sufficiently  clear.  Every  remission  of  fever  may  usher  in  an  unplea- 
sant and  dangerous  sequel  and  complication.  There  is  no  disease  so  treach- 
erous and  uncertain  as  is  scarlet  fever.  The  course  of  the  disease  in  any 
individual  case  is  very  greatly  influenced  by  the  general  type  of  the  local 
epidemic.  The  fatality  varies  with  the  characteristics  of  the  prevalent 
complaint  from,  one  to  fifty  per  cent.  The  disease  is  most  fatal  in  children 
of  from  two  to  four  years  of  age.  Mild  forms  will  recover  without  treat- 
ment while  severe  cases  sometimes  terminate  fatally  despite  it.  The  most 
dangerous  complication  is  the  necrotic  type  of  angina.  In  its  absence  a 
favorable  course  may  be  expected.  The  prognosis  is  unfortunately  influ- 
enced where  the  lymphatic  diathesis  exists.  Hardly  a  disease  is  met,  which 
gives  the  physician  so  great  a  sense  of  helplessness  as  do  the  toxic  or  necrotic 
forms  of  scarlet  fever. 

Prophylaxis  depends  upon  the  strict  isolation  of  the  patient  until  des- 
quamation is  completed  or  until  middle  ear  or  lymph  nodes  complications 
are  entirely  cured.  Usually  this  is  only  attainable  in  the  hospital. 

Thorough  disinfection  of  both  room  and  contents  after  the  patient's 
recovery  and  the  lifting  of  quarantine  is  essential.  (See  Page  579.) 

Treatment. — In  mild  cases  expectant  treatment  is  indicated.  While  it 
is  customary  even  in  mild  cases,  which  may  be  convalescent  within  a  few 
days  to  keep  patients  in  bed  for  three  or  four  weeks,  this  is  really  a  diplo- 
matic measure  to  relieve  the  physician  of  blame  should  nephritis  develop 
within  this  period.  In  hospitals  two  weeks  is  considered  a  sufficiently  long 
time.  The  writer  is  fully  assured  that  this  prolonged  rest  in  bed  is  not  in 
any  degree  preventive  of  nephritis.  Neither  to  any  demonstrable  extent 
is  the  strict  milk  diet  recommended  for  the  first  three  or  four  weeks 
(Pospischill).  Severe  nephritis  occurs  in  cases  in  which  both  of  these  mea- 
sures have  been  stringently  carried  out.  On  the  other  hand,  children  who  are 
permitted  to  run  out  of  doors  after  the  third  or  fourth  day  very  often  escape 
nephritis  altogether. 

The  diet  should  consist  at  first  of  milk  gruels  and  flour  puddings  with 
water  and  fruit  juices.  In  the  second  week,  toast,  barley  soup,  apple  sauce 
and  mashed  vegetables  may  be  added;  in  the  third  week  further  additions 
of  eggs  and  bread  may  be  made  while  meat  may  be  allowed  in  the  fourth 
week.  For  older  children  or  if  there  is  marked  difficulty  in  swallowing,  the 
milk  may  be  flavored  with  a  little  cocoa  with  which  milk  toast,  rice,  stewed 
apples,  oranges  etc.,  may  be  given. 

la  severe  cases  anorexia  is  often  marked  and  so  difficult  is  it  to  tempt 
the  appetite  that  a  little  meat  may  be  permitted.  To  very  sick  children, 


596  TEXT-BOOK  OF  PEDIATRICS 

especially  with  high  fever,  liquids  should  be  given  generously  and  if  neces- 
sary, by  enteroclysis.  In  young  children  water  serves  to  cleanse  the  mouth 
after  eating. 

The  fever  hardly  ever  requires  special  attention.  Antipyretics  must  be 
avoided,  since  they  are  apt  to  weaken  the  heart.  If  the  temperature  runs 
higher  than  39°-40°  C.  (102°-104°  F.)  and  is  accompanied  by  headaches  and 
a  sensation  of  heat,  etc.,  one  or  two  tepid  baths,  32°-33°  C.  (90°-92°  F.) 
will  give  good  results.  If  there  is  undue  somnolence  the  tepid  bath  may  be 
followed  by  a  cold  douche.  Very  high  temperatures  may  be  reduced  by 
wet  packs,  with  water  at  room  temperature,  continued  for  ten  or  fifteen 
minutes.  These  packs  may  be  repeated  two  or  three  times.  Cold  applica- 
tions to  the  chest  or  abdomen,  similarly  applied  and  repeated  once  or  twice 
a  day,  are  distinctly  beneficial.  If  the  fever  remains  persistently  above 
40°  C.  (104°  F.)  an  ice-cap  placed  alternately  upon  the  head  and  over  the 
region  of  the  heart  is  to  be  recommended. 

Cold  packs  are  not  always  borne  well  and  therefore,  must  be  carefully 
controlled. 

When  desquamation  begins,  a  daily  tepid  bath  is  to  be  recommended. 
This  aids  the  rapid  exfoliation  of  the  skin  and  prevents  the  scattering  of 
its  detritus.  For  the  latter  purpose,  the  inunction  of  the  body  surface  fol- 
lowing the  bath  with  a  bland  ointment,  as  ordinary  cold  cream,  is  also  useful. 

The  care  of  the  mouth  and  nose  demands  strict  attention.  Children 
who  are  old  enough  should  be  required  to  gargle  regularly  with  warm  water, 
a  very  dilute  solution  of  hydrogen  peroxide  or  of  boric  acid.  Younger  chil- 
dren should  be  given  water  immediately  after  eating. 

In  young  children,  suffering  with  severe  angina,  who  cannot  gargle,  the 
mouth  may  be  frequently  irrigated  with  one  of  the  above  solutions,  the  head 
being  held  forward,  provided  the  measure  can  be  accomplished  without  too 
much  resistance.  Sometimes  the  patient  comes  to  like  these  irrigations. 

If  the  inflammation  of  the  tonsils  and  the  pharynx  becomes  very  severe, 
cold  applications  to  the  neck  renewed  every  half-hour  or  oftener  prove  very 
acceptable.  If  the  fever  is  high  an  ice-bag  even  may  be  used.  Upon  the 
subsidence  of  the  fever,  ordinary  cold  applications  may  be  again  substi- 
tuted and  later  changed  to  fomentations.  If  an  exudate  appears,  gargling 
with  older  children  will  suffice ;  but  with  younger  patients  the  throat  should 
be  sprayed  several  times  a  day  with  a  solution  of  hydrogen  peroxide.  This 
is  particularly  efficient  when  irrigation  cannot  be  employed.  Insufflation 
with  equal  parts  of  sodium  sozoiodolate  and  precipitated  sulphur  has  an 
apparently  favorable  effect.  At  the  same  time  if  these  measures  cannot  be 
carried  out  without  the  use  of  extreme  force,  they  should  be  avoided.  In- 
flammation of  the  lips  resulting  in  rhagades  and  ulceration,  will  often  make 
the  opening  of  the  mouth  even  for  the  purpose  of  inspection,  painful.  The 
accumulated  secretions  should  be  removed  from  the  lips  frequently  and 
lanolin  should  be  freely  applied. 

In  diphtheroid  angina,  ice-bags  or  ice  packs  may  be  recommended  dur- 
ing the  first  day  of  the  attack.  A  little  later,  however,  tepid  or  hot  packs 
are  to  be  preferred.  If  the  lymph  nodes  are  swollen,  ice  may  be  applied  dar- 


THE  ACUTE  INFECTIOUS  DISEASES  597 

ing  the  continuance  of  high  fever,  but  it  should  be  replaced  very  soon  by 
cold  applications  renewed  hourly  and  later  by  cataplasms.  The  latter 
should  be  employed  systematically  with  nodal  swellings  of  long  duration. 
They  favor  resorption  when  this  remains  possible  and  if  not,  they  tend  to 
promote  softening.  An  abscess  should  be  incised  only  when  the  accumula- 
tion of  pus  is  large;  otherwise  only  dry  necrotic  tissue  may  be  encountered. 

The  nose  should  be  cleansed  regularly.  If  a  copious  discharge  appears, 
it  should  be  removed  with  pledgets  of  cotton,  and  the  nostrils  and  upper 
lip  should  be  protected  from  erosion  by  applications  of  lanolin.  Frequently 
the  insufflation  of  sodium  sozoiodolate  as  already  recommended  or  of  bolus 
alba  (Trumpp)  gives  relief. 

In  otitis  media,  with  reddening  and  bulging  of  the  drum  membrane  the 
instillation  of  a  ten  per  cent,  solution  of  phenol  in  glycerin  may  relieve  pain. 
Necrosis  of  the  membrane  indicated  by  its  white  color  usually  occurs  rapidly 
and  paracentesis  need  not  be  considered.  The  treatment  of  scarlatinal  oti- 
tis and  of  the  infections  of  the  mastoids  which  frequently  ensue,  is  of  the 
usual  order.  Mastoiditis  may  occur  even  as  late  as  from  three  to  six  weeks. 
Brain  abscess  and  sinus  thrombosis  are  rare.  Deafness  does  not  often  result. 

The  rheumatism  of  scarlet  fever  disappears  without  any  treatment. 
Rest  and  the  use  of  the  salicylates  however,  give  much  relief  from  pain  and 
probably  hasten  recovery. 

Daily  examination  of  the  urine  for  ten  to  forty  days  following  the  onset 
of  the  disease  may  be  readily  done  by  the  mother  at  home.  The  boiling  of 
the  urine,  with  the  addition  of  nitric  acid,  suffices.  It  should  be  insisted 
upon  in  every  case.  Upon  the  appearance  of  nephritis  it  is  well  to  measure 
the  twenty-four  hours'  output  of  urine.  Marked  diminution,  below  400  to 
500  c.c.  always  suggests  the  danger  of  uremia. 

If  uremia  develops,  blood  letting  to  the  extent  of  100  to  200  c.c.  often 
gives  excellent  relief.  In  the  event  of  uremic  convulsions  lumbar  puncture 
may  be  tried.  If  the  patient  in  coma  or  convulsions  cannot  take  water  by 
the  mouth,  large  quantities  should  be  given  by  enteroclysis.  For  further 
details  in  the  treatment  of  nephritis,  the  reader  is  referred  to  page  433. 

Stimulants  are  very  often  necessary  in  the  course  of  scarlet  fever,  since 
its  toxins  are  especially  destructive  to  the  heart  and  the  vasomotor  system. 
In  mild  cases  sufficient  stimulation  may  be  secured  by  adding  a  fairly  large 
allowance  of  strong  coffee  to  the  milk.  With  the  weakening  of  the  heart, 
indicated  by  a  small  and  frequent  pulse,  camphor  and  caffein  must  be  em- 
ployed (see  p.  415).  In  serious  cases  even  these  remedies  fail. 

Recently  the  serum  therapy  of  scarlet  fever  has  been  attempted  in  a 
number  of  instances.  Antisera  from  the  horse,  infected  with  streptococci 
are  generally  used.  Good  results  have  been  reported  in  a  certain  percentage 
of  these  cases,  but  final  judgment  upon  the  merits  of  the  method  must  be 
withheld.  Moser's  serum  seems  to  have  earned  the  fullest  confidence,  but 
even  with  its  use  results  have  been  attained  only  during  the  first  few  days 
of  the  disease  and  in  purely  toxic  cases.  Doses  of  150  to  200  c.c.  of  the 
serum  are  required  and  must  be  given  in  a  single  injection.  Since  with  such 
a  dose,  the  development  of  a  severe  grade  of  serum  disease  is  more  probable 


598  TEXT-BOOK  OF  PEDIATRICS 

than  a  favorable  effect  upon  the  scarlet  fever,  the  remedy  can  hardly  be 
said  to  be  indicated  in  general  practice. 

Convalescent  serum,  plasma  or  whole  convalescent  blood  has  been 
used  in  the  treatment  of  early  toxic  cases  of  scarlet  fever  both  in  America 
and  abroad,  and  has  given  encouraging  results  in  the  limited  number  of 
cases  observed  thus  far.  Reiss  and  Jungman  recommended  the  intravenous 
injection  of  50-100  c.  c.  of  pooled  convalescent  serum,  while  Zingher  made 
use  of  the  intramuscular  injection  of  whole  convalescent  blood  citrated  or 
iincitrated,  which  he  injected  in  quantities  of  120-240  c.  c.  The  convalescent 
serum  of  fresh  whole  blood  is  obtained  from  patients,  who  are  two  or  three 
weeks  convalescent  from  scarlet  fever.  These  donors  should  be  free  from 
syphilis  and  tuberculosis.  Fresh  normal  blood  has  no  specific  action  in 
septic  cases  of  scarlet  fever,  but  it  supplies  definite  nutritive,  stimulating 
and  normal  bacteriocidal  substances  and  can  be  used  to  advantage  in  toxic 
cases  where  convalescent  serum  or  blood  is  not  available. 

MEASLES  (MORBILLI) 

Measles  is  a  febrile  infectious  disease,  characterized  by  a  macular  erup- 
tion of  the  skin,  preceded  by  an  acute  affection  of  the  mucous  membranes 
of  the  mouth,  the  conjunctiva  and  the  upper  respiratory  tract. 

While  measles  is  supposed  to  be  a  very  ancient  disease,  it  was  not  clearly 
differentiated  from  scarlet  fever  and  small-pox  before  the  eighteenth  cen- 
tury. It  is  the  most  common  of  the  infectious  diseases  and  is  distributed 
over  the  entire  earth. 

Its  causative  organism  is  still  unknown,  in  spite  of  numerous  researches. 
The  virus  is  extremely  volatile,  since  the  disease  is  very  readily  conveyed 
from  one  person  to  another  and  even  without  direct  contact.  It  is  more- 
over, very  short-lived;  and,  consequently,  the  disease  is  almost  always 
carried  directly  from  the  sick  to  the  well.  The  infective  principle  dies  in 
a  very  short  time  outside  the  human  body.  Cases  of  indirect  transmis- 
sion by  infected  utensils  or  by  healthy  individuals  as  carriers  have  been  ob- 
served but  they  are  so  extremely  uncommon  that  practically  they  may 
be  disregarded. 

In  the  Faroe  Islands,  where  opportunities  of  observation  were  excellent, 
transmission  by  healthy  persons  was  never  proved.  Indirect  distribution 
of  the  disease  has  occurred,  in  all  probability,  only  when  the  uninfected 
carry  with  them  from  the  sick  bed  some  infective  material,  which  they  con- 
vey to  some  other  person  before  time  has  permitted  it  to  fall  below  the  tem- 
perature of  the  body.  Physicians  assuredly  go  directly  from  the  house  of 
the  measles  patient  to  other  homes  without  the  least  danger  of  carrying 
contagion.  Everything  points  to  the  conclusion,  that  the  virus  loosened 
from  the  diseased  mucous  membranes  is  sprayed  into  the  surrounding  atmos- 
phere by  sneezing  and  coughing.  In  former  years  in  fact,  successful  inocu- 
lation was  practiced  by  the  use  of  the  secretion  from  the  nose,  eyes,  or 
mouth  of  the  patient  with  measles. 

The  infectiousness  begins  in  the  prodromal  stage,  the  stage  of  the 
disease  covering  a  period  of  three  or  four  days  before  the  appearance  of  the 


THE  ACUTE  INFECTIOUS  DISEASES  599 

rash  and  it  persists  throughout  the  exanthem,  disappearing  within  eight  or 
ten  days,  or  even  less,  of  the  appearance  of  the  rash.  Infection  is  most  apt 
to  occur  two  or  three  days  before  the  outbreak  of  the  exanthem,  so  that 
secondary  cases  within  a  family  develop  in  eleven  or  twelve  days,  some 
two  weeks  intervening  between  the  entry  of  the  infection  and  the  eruption 
of  the  rash. 

Predisposition  to  measles  is  extraordinarily  great  among  all  peoples 
and  continues  throughout  life  even  to  old  age.  Infancy  alone,  presents  an 
exception.  The  disease  is  at  least  extremely  uncommon  during  the  first 
four  months  of  life.  Older  infants  have  it  in  very  mild  forms.  That  mea- 
sles occur  chiefly  as  a  disease  of  childhood  is  simply  due  to  the  fact,  that 
most  persons  are  infected  early  and  that  one  attack  confers  an  almost  abso- 
lute and  life-long  immunity.  Children  whose  mothers  suffer  from  the  dis- 
ease while  carrying  them  are  without  exception  unimmunized  thereby. 
A  second  attack  of  measles  is  a  great  rarity.  The  author  has  had  the  oppor- 
tunity of  observing  but  one  case  in  which  recurrence  could  be  proved  with- 
out question.  According  to  reports  current  among  mothers  two  or  three 
attacks  might  be  considered  usual;  reports  that  are  doubtless  due  to  the 
confusion  of  measles  with  all  manner  of  infectious  diseases  and  toxic  ery- 
themata.  The  prevalent  appearance  of  measles  in  early  life  is  evidence  of 
the  general  predisposition  and  the  almost  invariable  immunity  conferred 
by  the  one  attack. 

Measles  usually  appears  epidemically  and  spreads  rapidly,  reaching  its 
maximal  prevalence  in  a  short  time.  The  disease  disappears  as  rapidly 
wrhen  the  non-immunized  human  material  is  exhausted.  Small  isolated 
villages  may  escape  measles  for  ten  or  twenty  years,  until  some  case  is 
imported.  In  larger  towns  it  will  occur  in  distinct  epidemics  every  two  to 
four  years  (Fig.  156),  with  intervals  comparatively  free  of  cases.  In  the 
great  cities  single  cases,  which  carry  on  the  contagion  from  one  period  to 
another  are  always  to  be  found.  These  isolated  cases  may  cause  local  out- 
breaks, without  the  occurrence  of  large  epidemics.  If  the  disease  is  carried 
to  an  unfrequented  island,  where  it  has  never  been  or  in  which  there  has 
been  no  epidemic  for  decades,  the  entire  population  may  be  affected  with 
the  exception  of  its  young  infants.  Carefully  gathered  statistics  of  Faroe 
Islands  have  shown  that  99  per  cent,  of  its  people  have  been  susceptible  to 
the  disease.  Its  first  invasion  of  Samoa,  in  1893  caused  the  death  of  4000 
persons,  half  of  whom  were  adults.  Nearly  all  the  inhabitants  were  affected. 

Children  in  the  great  cities  are,  as  a  rule,  infected  between  the  ages  of 
two  and  six  years ;  nevertheless  this  cannot  be  said  to  be  the  period  of  great- 
est predisposition.  For  unknown  reasons  a  person's  predisposition  is  tem- 
porarily varied,  so  that  a  child  may  escape  the  first  opportunity  of  infection 
only  to  be  infected  later.  The  seasons  exert  no  essential  influence  upon  the 
development  of  epidemics.  Nevertheless,  a  certain  tendency  to  this  prev- 
alence of  the  disease  in  the  cold  months  and  especially  in  the  spring,  may 
be  recognized.  This  is  apparently  explained  by  the  greater  susceptibility 
of  the  respiratory  tract  at  these  seasons,  supported  by  the  well  justified 
assumption,  that  the  contagion  of  measles  enters  through  the  air  passages. 


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The  mortality  varies  widely  from  year  to  year  and  from  one  epidemic 
to  another.  In  large  cities  it  often  runs  as  high  as  three  to  five  per  cent,  at 
large  and  up  to  thirty  per  cent,  in  hospital  practice.  In  the  first  two  or  three 
years  of  life  the  fatality  is  greatest.  In  ordinary  epidemics  deaths  of  chil- 
dren of  over  five  years  are  uncommon. 

The  pathologic  findings  give  us  no  insight  into  the  nature  of  the  disease, 
but  usually  emphasize  its  fatal  complications.  If  a  case  comes  early  to 
autopsy  the  skin  lesions  are  still  prominent.  A  marked  hyperemia  is  found. 
About  the  efflorescence,  markedly  paled  in  death,  the  small  vessels  of  the 
papillae  are  greatly  distended  and  are  surrounded  by  a  round  cell  infiltra- 
tion. These  phenomena  are  especially  marked  about  the  sebaceous  glands 
and  the  hair  follicles.  They  probably  explain  the  papillary  eminences  in 
the  centre  of  the  erupted  spots  (Heubner). 

Symptoms. — Commonly  it  is  possible  to  recognize  four  stages  in  mea- 
sles; first,  the  incubation  period;  second,  the  prodromal  or  initial  period, 


flr 


FIG.  156. — Morbidity  in  the  city  of  Basel,  Switzerland,  of  measles  and  scarlet  fever  from  1883-1890 

graphically    represented    according    to    the    frequency  during  the  various   months.     Measles 

Scarlet  fever 

the  stage  of  the  enanthem;  third,  the  exanthem;  and  fourth,  the  stage  of 
convalescence. 

The  time  elapsing  between  the  infection  and  the  appearance  of  the  rash, 
that  is,  the  incubation  plus  the  prodromal  period,  covers  with  marked  regu- 
larity from  thirteen  to  fifteen  days.  This  circumstance  often  affords  a  clue 
to  the  source  of  the  infection.  This  period  is  very  exceptionally  extended 
to  sixteen  or  even  twenty  days,  the  delay  being  occasioned  frequently  by 
the  presence  of  intercurrent  infectious  diseases. 

The  stage  of  incubation  alone,  usually  covers  ten,  or  eleven  days,  and 
the  prodromes  occupy  three  or  four  days.  Cases,  however,  are  often  seen 
in  which  the  actual  incubation  takes  only  from  seven  to  nine  days  and 
the  prodromes  a  matter  of  five  to  seven  days,  the  rash  still  appearing  within 
fourteen  days. 

The  disease-picture  in  general  shows  fairly  uniform  features.  The  incu- 
bation period  is  hardly  ever  marked  by  any  noticeable  disturbances.  Now 
and  then  there  is  slight  disorder  of  digestion,  catarrh,  and  malaise.  The 


THE  ACUTE  INFECTIOUS  DISEASES  601 

temperature  varies.  At  times  it  is  febrile  and  very  definitely  and  signifi- 
cantly so  for  a  few  days  before  the  onset  of  prodromes. 

The  prodromal  stage  or  enanthem  is  characterized  by  an  affection  of 
the  mucous  membranes  of  the  eyes,  mouth  and  respiratory  passages.  This 
stage  sometimes  has  an  insidious  onset,  but  commonly  is  accompanied  by 
distinct  signs  of  fever  and  catarrh.  The  child  previously  happy  and  well 
suddenly  becomes  tired,  the  conjunctiva  grows  red,  a  nasal  discharge  and 
an  annoying  cough  begins.  The  reddening  and  swelling  of  the  conjunctiva 
may  be  quite  severe  and  may  be  accompanied  by  a  free  flow  of  tears,  by 
profuse  wateiy  or  purulent  secretion,  increasing  from  day  to  day  and  by 
marked  photophobia. 

The  nasal  mucosa  swells,  frequent  sneezing  occurs  and  a  thin  and  some- 
times purulent  discharge  appears. 

Simultaneously,  or  within  a  few  days  a  dry  hard  cough  sets  in,  which  is 
unaccompanied  by  any  auscultatory  signs.  The  laryngeal  quality  of  the 
cough  and  the  hoarseness,  which  develops  upon  crying  show  that  the  vocal 
chords  are  affected.  In  patients  especially  predisposed  severe  attacks  of 
pseudocroup  often  occur.  The  oral  mucous  membranes,  the  tonsils  and 
the  pharynx  are  injected  and  show  a  hypersecretion  of  mucus. 

The  temperature  during  the  early  prodromata  rises  to  38.5°-39.5°  C. 
(101°-103°  F.).  With  marked  remissions  it  falls  even  to  the  normal  point 
on  the  second  or  the  third  day,  the  drop  giving  way  to  a  sharp  rise  upon  the 
appearance  of  the  eruption.  At  the  onset  the  general  health  is  frequently 
but  slightly  affected,  although  severe  disturbance  may  follow.  Headache, 
loss  of  appetite,  occasional  vomiting,  at  times  diarrhceic  stools,  and  broken 
sleep  incidental  to  the  severe  coughing  may  ensue.  Within  two  or  three 
days  these  symptoms  subside  with  the  fall  of  temperature,  to  recur  more 
severely  with  the  development  of  the  skin  eruption. 

The  entire  picture  resembles  at  first  that  of  a  severe  coryza,  of  influenza 
or  of  la  grippe.  Not  infrequently  the  inexperienced  or  superficial  observer 
makes  the  correct  diagnosis  only  when  the  eruption  appears.  During  this 
initial  period,  however,  a  careful  examination  of  the  oral  cavity  often  makes 
it  possible  to  establish  the  diagnosis  of  measles  several  days  before  the  ap- 
pearance of  the  rash. 

The  reddening  of  the  tonsils,  the  throat  and  the  oral  mucosa  does  not 
differ  at  first  from  the  injection  observed  in  any  other  severe  catarrhal 
affection.  But  soon,  a  distinctive  sign  by  way  of  spots  characteristic  of 
measles  appear  upon  the  buccal  mucous  membrane.  Their  appearance 
antedates  by  two  or  three  days  the  skin  eruption.  Their  significance  was 
first  clearly  recognized  by  Koplik  and  they  have  become  known  as  Koplik's 
spots.  Upon  the  dull  red  surface  of  the  mucosa,  usually  opposite  the  lower 
molars,  a  number  of  these  bright  red  spots  the  size  of  a  pinhead  are  to  be 
seen.  At  the  centre  of  each  is  a  smaller  white  point,  which  looks  like  a  fine 
granule  of  salt  (Fig.  157).  This  white  point  feels  as  if  raised;  it  consists 
of  fatty  epithelial  detritus,  and  may  be  rubbed  off  if  a  little  force  is  used. 

The  number  of  the  Koplik's  spots  varies  greatly.    At  times  only  two  or 


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three  are  present  and  are  so  small  as  to  be  very  difficult  to  find;  especially 
so  when  the  red  base  is  lacking,  which  is  not  at  all  uncommon,  particularly 
in  anemic  patients. 

The  spots  are  best  seen  by  holding  the  cheek  away  from  the  teeth  with 
a  wide  looped  tongue-blade.  In  other  oases  they  are  very  distinct  and 
numerous,  spreading  over  the  entire  mucous  membrane  and  resembling 
thrush.  They  are  often  found  upon  the  inner  surface  of  the  lower  lip.  The 
spots  increase  in  size  and  number  until  the  skin  rash  erupts  and  then,  within 
a  day  or  two.  entirely  disappear.  The  little  white  heads  first  fall  away,  some- 
times leaving  hemorrhagic  spots,  and,  later  the  red  base  gradually  fades. 

Occasionally  Koplik's  sign 
appears  as  early  as  four  days 
before  the  exanthem;  and  in 
one  occasion  it  has  been  seen 
on  the  fifth  preceding  day. 
As  evidence  they  are  ex- 
tremely important,  since  they 
attend  no  other  disease  and 
permit  a  positive  diagnosis 
upon  their  presence  alone. 
However,  the  recognition  of 
Koplik's  sign  is  not,  in  itself, 
alway  easy.  Bright  daylight, 
good  eyesight  and  careful 
observation  are  requisite  for 
the  discovery  of  the  spots, 

_  _.  which   are    few    and    small. 

Thrush    is    easily    excluded. 

>^  Small    crumbs    of    toast 

minute  particles  of  curd 
cause  some  confusion,*"  but 
these  are  easily  wiped  away. 
If  the  patient  is  seen  one  or 
two  days  before  the  appear- 
ance of  the  exanthem  the  sign 
is  seen  in  nearly  all  cases.  If  the  physician  is  not  called  until  the  rash  has 
appeared  these  spots  may  have  passed  away.  They  are  most  likely  to  be 
absent  in  infants,  in  cachectic  patients  and  in  those  persons  in  whom  the 
affection  of  the  mucous  membranes  is  slight. 

The  true  enantheni  in  the  mouth  appears  a  day  or  two  before  the  skin 
eruption  and  usually  later  than  the  Koplik's  spots.  It  is  a  rnacular  eruption 
on  the  mucous  membranes  analogous  to  the  later  skin  eruption.  In  small 
star-shaped,  red  spots,  which  may  be  as  large  as  a  lentil,  it  appears  sprinkled 
over  the  mucosa  of  the  soft  and  hard  palate  and  the  epiglottis.  This  enan- 
them,  however,  is  not  so  distinct  nor  so  characteristic  as  Koplik's  sign; 
and  in  comparison  with  it,  has  lost  value  as  a  means  of  determining  an 
early  diagnosis. 


or 


FIG.  157. — Koplik's  spots.  Abovethelower  molars,  under 
the  tongue  blade,  the  five  whitish  spots  with  red  areola  (act- 
ually smaller). 


THE  ACUTE  INFECTIOUS  DISEASES 


603 


The  Exanthematous  or  Florid  Stage. — All  the  initial  symptoms  usually 
grow  more  severe  on  the  day  preceding  the  appearance  of  the  exanthem. 
The  fever  which  prior  to  this  time  rnay  have  shown  a  characteristic  fall, 
rises  high  and  the  reddening  and  swelling  of  the  conjunctiva,  the  photo- 
phobia and  the  coryza  become  more  intense.  The  cough  is  hoarser  and 
more  annoying.  ^  The  general  well-being  is  markedly  disturbed.  The  physi- 
cian called  in  this  stage  catching  the  suspicion  of  measles  from  the  attendant 
circumstances,  usually  finds  on  inspection  the  first  indications  of  a  rash  in 
the  form  of  small  red  spots,  commonly 
located  about  the  ears,  on  the  face 
(Fig.  158)  the  neck  or  the  scalp.  From 
these  points  the  rash  spreads  rapidly 
to  the  back,  the  trunk  and  later  to 
the  upper  arms  and  finally  to  the  legs. 
By  about  the  second  day  it  covers  the 
entire  body  arid  in  still  another  day  is 
fully  developed.  The  sight  of  the  entire 
body  covered  with  these  bright  red 
spots  is  an  impressive  picture. 

Each  individual  spot  begins  as  a 
small  follicular  elevation  rapidly  en- 
larging to  the  size  of  a  pinhead  or  a 
pea.  It  may  be  flattened  at  first,  but 
commonly  it  is  raised  from  the  very 
beginning  and  is  very  soon  marked  by 
a  small  but  prominent  papilla  at  its 
centre.  This  central  papilla  corre- 
sponds to  a  sebaceous  gland  or  a  hair 
follicle.  The  color  is  at  first  a  bright 
red,  gradually  deepening  to  a  flaming 
red.  As  the  spots  enlarge  they  assume 
an  irregular  star-shaped  outline  and 
are  uniformly  raised  above  the  level 
of  the  skin.  Sometimes  a  small  vesicle 
appears  at  the  papular  centre  of  the 
spot.  The  prominence  is  distinctly 
palpable  and  may  be  seen  if  the  light 
falls  across  it  at  a  tangent.  These  minute  papular  elevations  at  the  cen- 
tre are  characteristic  and  two  or  three  of  them  may  be  found  on  the 
larger  spots. 

The  early  eruption  is  scant  and  the  individual  spots  are  small  but  they 
increase  rapidly  in  size  while  new  ones  continually  crop  out  between  them. 
In  many  parts  of  the  body  they  become  confluent  and  cover  large  areas  of 
surface  so  that,  at  times  the  clear  skin  only  forms  a  few  small  intervening 
islands  (Fig.  159).  The  face,  the  trunk  and  the  back  are  most  frequently 
the  seat  of  such  a  diffuse  eruption.  In  nervous  patients  the  rash  may  cause 
severe  irritation.  When  it  is  fully  developed  and  has  reached  its  greatest 


FIG.  158. — Beginning  measles  eruption  in  the 
face,  which  with  the  conjunctiva  and  photo- 
phobia gives  a  typical  physiognomy. 


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Fio.  159. — The  exanthem  of  measles  at  the  beginning,  the  separate  eruptions  are  still  small. 

intensity,  it  does  not  continue  for  long  in  full  bloom.  After  a  veiy  few  days 
it  begins  to  abate  over  the  upper  parts  of  the  body  and  recedes  rapidly  in 
the  order  of  its  appearance.  The  recession  usually  takes  about  two  days,  so 


THE  ACUTE  INFECTIOUS  DISEASES  605 

that  it  disappears  within  four  or  five  days  of  its  outbreak.  The  early  erup- 
tion usually  disappears  completely  upon  pressure,  but  in  that  of  later  date 
a  slight  discoloration  remains  in  consequence  of  the  fact,  that  some  coloring 
matter  has  escaped  from  the  blood.  This  pigmentation  becomes  more  and 
more  distinct  especially  in  robust,  highly  vascular  individuals.  It  remains 
for  ten  or  even  twenty  days  after  the  rash  has  disappeared.  A  delayed 
diagnosis  of  measles  may  often  be  made  from  this  peculiarity  alone. 

A  fine  desquamation  of  the  skin  is  observed  as  soon  as  the  rash  begins 
to  pale.  Over  the  trunk  and  the  extremities  this  desquamation  is  so  slight 
and  so  minute  that  it  is  often  overlooked,  so  that  one  is  hardly  justified  in 
terming  it  a  fourth  stage  of  the  disease.  On  the  face  and  occasionally  on 
other  parts  of  the  body  it  is  often  more  apparent  and  bran-like  in  appear- 
ance. The  coarse  lamellated  desquamation  of  scarlet  fever,  particularly  on 
the  hands  and  feet,  is  never  found  in  measles. 

The  temperature  curve  in  uncomplicated  measles  is  often  character- 
istic. The  peculiar  drop  occurring  one  or  two  days  before  the  beginning  of 
the  exanthem  has  already  been  mentioned.  As  the  rash  appears  the  tem- 
perature rises  quite  high  and  reaches  its  maximum  within  twenty-four 
hours.  It  usually  remains  at  this  height  for  another  day  until  the  rash  is 
fully  developed  and  has  reached  its  most  active  stage,  falling  by  crisis  to 
the  normal  level  in  a  day  or  two  (Fig.  160).  Even  in  mild  cases  the  tem- 
perature rises  comparatively  high;  39°-40°  C.  (102°-104°  F.)  is  common  and 
an  increase  to  40°  or  41°  C.  (101°-105°  F.)  is  not  uncommon.  If  during 
the  stage  of  the  exanthern  the  fever  remains  high  for  more  than  four  days 
complications  should  always  be  suspected.  The  temperature  curve  de- 
scribed is  the  rule,  but  variations  frequently  occur  without  indicating  any 
disturbance  in  the  normal  course  of  the  disease.  Thus  the  temperature 
may  fall  by  lysis  during  the  height  of  the  exanthem:  but  two  distinct  rises 
may  almost  always  be  recognized,  the  one  in  the  prodromal  period  and  the 
second  during  the  first  or  second  day  of  the  exanthem. 

During  the  florid  stage,  the  general  health  of  the  patient  is  usually  mark- 
edly disturbed  and  he  is  seriously  troubled  by  cough,  photophobia  and 
headache.  Delirium  may  appear  with  the  development  of  high  fever.  The 
appetite  is  completely  lost  and  even  fluids  are  obstinately  refused. 

The  conjunctivitis  increases  during  the  florid  exanthematous  stage. 
Tho  lids  are  swollen  and  the  free  secretion  becomes  purulent  and  causes 
agglutination  of  the  lids  in  the  morning.  Inspection  of  the  bright  red  con- 
junctiva inflamed  to  the  edge  of  the  cornea  is  more  difficult  because  of  the 
severe  photophobia. 

The  rhinitis  also  increases.  Severe  swelling  of  the  nasal  mucosa  makes 
breathing  difficult.  The  purulent  secretion  from  the  nose  erodes  the  upper 
lip.  Epistaxis  occurs  from  time  to  time. 

Otitis  media  frequently  accompanies  these  conditions.  It  arises  from 
the  passage  of  the  inflammation  through  the  Eustachian  tube.  Catarrhal 
otitis  media  is  indeed  a  frequent  finding  and  seldom  gives  symptoms,  but 
the  purulent  form  is  also  common  in  younger  children  and  particularly  in 
those  with  adenoids. 


606 


TEXT-BOOK  OF  PEDIATRICS 


The  tongue  is  dry  and  heavily  coated.  The  pharynx,  tonsils  and  palate 
are  of  a  bright  red  hue  and  over  the  latter  the  enanthem  may  still  be  recog- 
nized. The  buccal  mucous  membrane  is  dull,  no  longer  glistening  and  often 
still  shows  the  Koplik's  spots  on  the  first  and  even  the  second  day.  A  white 
pasty  deposit  is  often  found  on  the  gums  and  is  easily  removed.  This  is 
found  also  in  other  severe  infectious  diseases  but  is  never  so  marked  as  it 
is  in  measles.  The  lips  become  diy,  chapped,  slightly  fissured  and  painful, 
a  condition  which  may  embarrass  the  opening  of  the  mouth  and  interfere 
with  feeding. 

The  early  and  annoying  dry  cough  often  ceases  suddenly  upon  the 
appearance  of  the  rash,  giving  the  impression,  that  the  hyperemia  of  the 
deeper  mucous  membranes  has  been  relieved  by  the  development  of  the  skin 
eruption.  Symptoms  of  laryngeal  stenosis  may  abate  in  a  similar  fashion. 

The  lungs  usually  seem  normal  on  percussion  and  auscultation,  but 


U 10—80— 34 


FIG.  100. — Typical  temperature  curve  in  a  mild  case  of  measles,  four-year-old  girl. 


quite  frequently  medium  and  fine  moist  rales  are  heard.  If  there  is  a  marked 
degree  of  bronchitis  the  respiration  is  visibly  difficult  and  labored. 

The  heart  and  the  blood-vessels  commonly  show  nothing  abnormal. 
The  pulse  is  rapid  in  correspondence  with  the  fever.  In  uncomplicated 
cases  in  young  children  its  frequency  often  runs  to  160  or  180. 

The  blood  in  the  early  part  of  the  incubation  period  shows  an  increase  of 
leucocytes.  During  its  later  days  there  is  some  leucopenia  (Hecker)  result- 
ing chiefly  from  a  decrease  of  lymphocytes. 

This  leucopenia  is  most  distinct  during  the  exanthem.  At  this  time 
the  eosinophiles  disappear. 

The  kidneys  are  not  affected  in  ordinarily  mild  cases.  During  the  high 
fever  a  transient  albnminuria  is  often  found.  Severe  cases  occasionally 
develop  acute  nephritis  at  the  height  of  the  disease.  This  quickly  heals. 
If  nephritis  appears  during  convalescence,  in  the  third  or  fourth  week  it 
probably  always  means  that  scarlet  fever  has  been  mistaken  for  measles. 
A  distinct  diazo-reaction  is  invariably  present  in  the  urine  during  the  florid 
stage.  An  intravenous  injection  of  this  urine  into  guinea  pigs  shows  that  it 
is  toxic. 

The  stools,  especially  in  the  young  are  often  diarrhoaic  at  the  beginning 


of  the  attack  and  this  weakens  the  patient.  During  hot  seasons  and  in 
certain  epidemics  the  intestinal  tract  is  sometimes  seriously  affected.  In 
young  children  colitic  symptoms  not  infrequently  develop,  and  are  extremely 
obstinate,  causing  frequent  slimy  stools,  which  may  induce  exhaustion 
and  death.  In  these  instances  the  intestinal  mucosa  shows  marked  follieu- 
lar  swelling  and  even  extensive  ulceration. 

The  palpable  lymph  nodes  are  always  slightly  enlarged.  In  severe 
attacks  occurring  in  exudative  or  tuberculous  patients  the  swelling  of  the 
cervical  nodes  is  often  veiy  great.  The  spleen  commonly  shows  no  demon- 
strable enlargement. 

The  Stage  of  Convalescence. — With  the  fall  of  fever  all  the  general  symp- 
toms subside  rapidly.  The  clinical  condition  changes  completely  within  a 
day  or  two.  The  appetite  returns  and  sleep  becomes  normal.  The  cough 
becomes  less  frequent  and  looser.  The  inflammatory  changes  of  the  eyes, 
nose,  mouth,  lips  and  bronchial  tubes  improve  more  gradually,  but  never- 
theless, so  rapidly  that  ordinary  cases  are  fully  convalescent  within  a  week 
after  the  appearance  of  the  eruption  and  are  entirely  normal  eight  or  ten 
days  later.  The  pigmentation  of  the  skin  over  the  eruptive  areas,  a  slight 
pallor,  a  lessening  of  the  usual  turgor  and  at  times,  a  slight  catarrh  of  the 
affected  mucous  membranes  may  remain  for  a  short  time  longer. 

Unusual  Course  and  Complications. — A  relatively  large  number  of  cases 
of  measles  conform  to  the  above  outline  arid  follow  such  a  definite  course. 
Anomalies,  of  course,  are  much  less  frequent  than  is  the  occurrence  of  com- 
plications, chiefly  affecting  the  respiratory  tract. 

Cases  are  seen  so  light  that  the  prodromes  are  hardly  noticeable  and 
the  disease  is  observed  by  the  parents  only  when  the  rash  appears.  Again 
the  exanthematous  period  may  often  pass  in  two  or  three  days  without 
marked  fever  and  without  affecting  materially  the  general  condition  of 
the  child. 

In  rare  instances  a  severe  toxic  form  of  measles  is  seen.  At  the  very 
onset  of  the  exanthematous  stage,  the  patient  becomes  extremely  ill,  with 
high  fever,  somnolence,  small  arid  veiy  rapid  pulse,  and  unusually  severe 
catarrhal  symptoms  which  are  followed  by  an  intense  exanthern  the  tem- 
perature going  to  40°-42°  C.  (101°-106°  F.)  and  death,  preceded  by  the  signs 
of  asthenia,  ensuing  in  a  few  days.  This  fatal  course  is  most  frequently 
seen  among  children  with  a  status  lyrnphaticus.  Occasionally  the  discovery 
of  streptococci  in  the  blood  shows,  that  one  has  had  to  deal  with  a  septic 
measles.  The  mildness  or  severity  of  individual  cases  is  frequently  deter- 
mined by  the  nature  of  a  given  epidemic. 

In  infancy,  measles  is  often  extraordinarily  mild.  The  fever  and  the 
catarrh  are  insignificant;  the  exanthem  remains  light  and  pale  and  the  recog- 
nition of  the  disease  may  be  very  difficult  and  the  more  so  since  Koplik's 
sign  is  often  very  slight  or  entirely  absent  at  this  age. 

Adults  are  usually  more  severely  affected  by  measles  than  are  children 
although  death  is  rare  under  ordinary  circumstances. 

Among  sick  and  tuberculous  children  the  course  of  measles  is  often  very 


608  TEXT-BOOK  OF  PEDIATRICS 

severe.  The  skin  eruption  may  remain  slight,  but  pulmonary  complica- 
tions develop  very  readily  or  a  new  spread  of  the  tuberculous  infection 
results  in  death. 

Certain  deviations  with  respect  to  individual  symptoms  may  be  noted. 
Fever  may  remain  very  low  and  the  characteristic  curve  may  be  entirely 
lacking.  Fall  of  temperature  by  lysis  in  the  final  stages  is  common  even  in 
the  usual  course  of  the  disease.  One  should  always  be  prepared  for  compli- 
cations when  the  temperature  does  not  fall  with  the  disappearance  of  the 
eruption,  or  in  the  event  that  it  rises  again  after  a  few  days. 

Afebrile  measles  is  a  great  rarity,  but  cases  with  very  slight  and  tran- 
sient fever  are  common.  They  are  often  seen  among  cachectic  infants. 
The  exanthem  and  the  catarrhal  symptoms  may  be  so  slight  as  to  be  en- 
tirely overlooked. 

The  exanthem  shows  numerous  variations,  even  though  it  be  so  typical 
and  so  well  developed  in  the  great  majority  of  cases  that  the  laity  can  make 
a  correct  diagnosis.  In  extremely  rare  instances  the  eruption  of  measles  is 
preceded  by  a  transient  scarlet  rash. 

There  is  much  difference  of  opinion  as  to  whether  a  form  of  measles 
occurs  without  exanthem  in  which  only  the  fever  and  the  catarrhal  symp- 
toms appear.  Since  the  incubation  period  is  a  very  constant  one  (fourteen 
days)  it  would  seem  that  this  question  should  be  easily  settled  in  private 
practice.  Most  authors  admit  that  they  have  never  seen  a  case  of  measles 
without  exanthem.  Through  many  years  of  private  practice  and  in  spite  of 
special  pains  in  the  observation  of  hundreds  of  cases,  the  writer  has  never 
noted  such  a  case,  the  diagnosis  of  which  could  be  clearly  made  by  the  aid 
of  Koplik's  spots.  Recently,  however,  he  has  seen  one  instance  occurring  in 
the  midst  of  a  household  epidemic.  It  occurred  in  a  feeble  infant  of  four  and 
a  half  months  of  age.  The  patient  became  ill  after  the  usual  incubative  inter- 
val with  fever,  catarrh  and  distinct  Koplik's  spots,  but  it  never  showed 
even  a  trace  of  an  exanthem. 

Cases  in  which  the  exanthem  is  slight,  appearing  in  but  a  few  small 
areas,  and  disappearing  completely  within  a  day  or  two  are  frequently 
encountered.  Such  cases  are  less  common  in  the  very  mild  forms  of  the 
disease  than  among  cachectic  children  or  those  who  are  ill  with  other  diseases. 
An  incomplete  and  weak  exanthem  is  seen  also  in  cases,  which  develop 
severe  complications  such  as  bronchiolitis  or  pneumonia  in  the  prodromal 
stage.  If  pneumonia  appears  at  the  outbreak  of  the  skin  eruption,  the 
development  of  the  exanthem  may  be  arrested  and  the  child  becomes  cya- 
notic  and  pale,  so  that  the  rash  can  hardly  be  seen.  This  is  a  bad  indi- 
cation. It  has  given  the  laity  its  general  fear  of  the  "going  in"  of  the 
measles.  Similarly  it  appears,  that  the  development  of  the  rash  in  other 
than  its  regular  order  of  appearance,  or  its  incompletion  is  an  unfavor- 
able sign. 

Even  cases  of  measles  which  from  the  first  pursue  an  entirely  favorable 
course,  may  either  show  a  localized  or  a  general  eruption  of  a  hemorrhagic 
quality.  This  has  no  serious  significance.  The  writer  has  seen  a  severe 
hemorrhagic  exanthem  in  three  children  of  one  family,  all  having  but  a 


THE  ACUTE  INFECTIOUS  DISEASES  609 

mild  form  of  the  disease.  When  the  eruption  is  distinctly  cyanotic  the  con- 
dition is  more  grave,  since  it  indicates  an  impaired  circulation.  The  rare 
cases  in  which  hemorrhages  into  the  skin  occur  as  a  result  of  sepsis  and  in 
which  hemorrhages  from  the  mucous  membranes  of  the  nose,  intestinal 
tract,  etc.,  also  appear  must  be  differentiated  carefully  from  the  ordinary 
hemorrhagic  exanthem.  Occasionally  one  may  have  to  deal  with  a  general 
sepsis  in  which,  from  the  very  first,  an  appearance  of  a  macular  exanthem 
simulates  measles. 

A  preexisting  eczema  of  the  face  will  often  become  a  brighter  red  and 
more  macular  two  or  three  days  before  the  appearance  of  the  rash.  Very 
frequently  one  finds  eczema  aggravated  or  redeveloped  by  measles,  or 
again,  suppressed  during  the  passing  eruption. 

The  character  of  the  exanthem  of  measles  often  presents  variations 
that  are  important  from  a  diagnostic  standpoint.  The  efflorescence  may 
from  the  first  be  so  distinctly  papular  as  to  make  one  think  of  chicken-pox. 
At  other  times  they  do  not  rise  above  the  level  of  the  skin.  This  is  especially 
true  in  the  anemic.  Occasionally  they  are  vesicular  or  urticarial.  Gan- 
grene of  the  skin  has  been  known  to  follow  the  exanthem.  The  writer  has 
seen  one  instance  in  which  the  entire  musculature  of  the  upper  arm  was 
exposed  in  consequence. 

A  recrudescence  of  measles  must  be  mentioned  as  of  very  rare  occurrence 
appearing  after  an  interval  varying  from  two  to  eight  weeks. 

The  involvement  of  the  mucous  membranes  varies  greatly  in  intensity. 
In  the  eye  all  degrees  of  inflammation  are  seen  from  a  slight  conjunctivitis 
to  a  severe  blennorrhea,  which  may  lead  to  a  clouding  of  the  cornea  and 
destruction  of  the  eye.  Frequently  a  severe  blepharitis  occurs  which  with 
the  conjunctivitis  may  require  weeks  for  recovery.  With  a  marked  rhinitis 
an  erosion  of  the  nostrils  and  diphtheroid  ulcerations  of  the  upper  lip  are 
not  uncommon.  At  the  beginning  of  the  prodromal  stage  a  catarrhal  or 
lacunar  angina  sometimes  develops  and  if  the  usual  symptoms  in  the  mu- 
cous membranes  are  not  apparent,  it  may  cause  some  confusion  until  the 
rash  appears. 

The  inflammation  of  the  mucosa  of  the  mouth  may  lead  to  the  formation 
of  deep  and  obstinate  aphthous  sores  or  ulcerations.  These  may  occur  also 
on  the  lips  giving  great  difficulty  in  opening  the  mouth.  A  comparatively 
large  percentage  of  cases  of  noma,  a  rare  condition,  appears  in  measles 
patients  especially  if  these  are  of  an  asthenic  type.  An  unusual  localiza- 
tion of  noma  is  on  the  vulva  which,  in  ordinary  cases  shows  only  a  moder- 
ate inflammation  with  a  thin  purulent  secretion. 

Laryngitis  may,  at  times,  become  very  severe,  even  in  the  enanthema- 
tous  stage,  causing  intense  hoarseness,  attacks  of  pseudocroup  and  persist- 
ent stenosis.  It  may  so  closely  simulate  true  croup,  that  the  patient  may 
be  placed  in  an  isolation  ward  for  diphtheria.  The  laryngeal  symptoms 
generally  disappear,  however,  so  soon  as  the  rash  develops.  The  more 
severe  grades  of  inflammation  occasionally  cause  ulcerations  of  the  vocal 
chords  and  adjacent  surfaces.  This  may  result  in  hoarseness,  and  even 
39 


610  TEXT-BOOK  OF  PEDIATRICS 

aphonia,  with  a  moderate  degree  of  stenosis,  persisting  for  many  months 
and  yielding  only  to  energetic  treatment. 

Bronchitis  may  become  very  diffuse  even  at  an  early  stage  and  may 
give  rise  to  many  medium  and  fine  rales  and  to  dyspnoea.  More  commonly 
however,  a  widespread  bronchitis  is  observed  in  the  exanthematous  stage. 
Very  often  it  is  of  a  capillary  type  and  affects  the  posterior  lung  areas.  At 
times  it  involves  the  entire  lung  and  frequently  causes  death. 

Grave  forms  of  bronchitis  and  pneumonia  are  the  more  usual  compli- 
cations of  measles.  The  younger  the  patient  the  more  liable  are  they  to 
occur.  After  the  third  or  fourth  year  they  become  much  less  common. 
Weak  and  rickitic  children  are  the  easiest  victims. 

Pneumonia,  the  most  frequent  and  the  most  fatal  complication  of  mea- 
sles may  arise  from  an  initial  bronchitis.  In  rare  instances  it  develops  even 
in  the  prodromal  stage;  more  frequently  it  coincides  with  the  onset  of  the 
rash;  and  still  oftener  it  follows  a  few  days  later.  The  earlier  its  develop- 
ment the  more  severe  it  is.  The  more  incomplete  the  eruption  or  the  more 
rapid  the  disappearance  of  the  rash  before  it  reaches  the  florid  stage,  the 
greater  the  likelihood  of  this  complication.  Usually  it  is  of  the  broncho- 
pneumonia  type.  Often  it  develops  in  this  form  so  rapidly  and  so  mas- 
sively, that  if  an  entire  lobe  is  involved  the  clinical  picture  resembles  very 
closely  that  of  lobar  pneumonia,  excepting  that  its  course  is  more  pro- 
tracted and  that  the  critical  fall  of  temperature  is  wanting.  In  other  cases 
it  develops  insidiously  and  presents  no  definite  findings  for  several  days.  The 
reappearance  of  fever  or  an  arrest  of  the  fall  of  temperature  with  the  occur- 
rence of  dyspnoea  alone  points  suspiciously  in  this  direction  (Fig.  161). 

Pneumonia  in  measles  frequently  terminates  fatally.  Although  recov- 
ery sometimes  is  seen  even  after  the  disease  has  dragged  along  for  weeks. 
A  peculiar  form,  happily  uncommon,  causes  a  necrotic  destruction  of  the 
affected  lung  tissue  (Ileubner). 

The  frequency  of  this  complication  varies  within  wide  limits  in  different 
epidemics  and  with  some  relation  to  the  season  of  the  year.  The  fact,  espe- 
cially emphasized  by  French  authors,  that  the  pneumonia  of  measles  is 
often  contagious,  is  remarkable.  One  patient  in  a  measles  ward  contract- 
ing pneumonia  may  convey  the  latter  disease  to  other  patients  in  the  same 
ward.  This,  in  itself,  shows  how  very  liable  cases  of  measles  are  to  second- 
ary infections.  The  contagious  element,  however,  in  these  cases,  is  not  the 
pneumonia  itself,  but  rather  the  causative  secondary  bronchitis,  although 
the  infective  organism  is  either  the  pneumococcus  or  the  streptococcus. 
The  author  has  observed,  that  with  the  coincidence  of  epidemics  of  both 
measles  and  la  grippe,  the  complicating  pneumonia  of  measles  is  unusually 
common.  The  development  of  measles  with  pertussis  is  especially  unfa- 
vorable since  it  increases  the  liability  to  pulmonary  complications. 

Pleurisy  is  frequently  associated  with  broncho-pneumonia.  It  is  usually 
fibrinous  or  seropurulent  and  readily  escapes  observation  often  being 
covered  only  at  autopsy.  Large  exudates  are  unusual  and  when  they  occur 
are  almost  always  purulent  and  of  streptococcic  type,  and  must  be  drained 
by  rib  resection. 


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612  TEXT-BOOK  OF  PEDIATRICS 

Otitis  media,  the  frequency  of  which  has  already  been  noted,  often 
causes  rupture  of  the  tympanic  membrane,  with  purulent  discharge.  It  is 
much  more  benign  than  that  of  scarlet  fever  and  usually  heals  without 
causing  permanent  injury.  Inflammation  of  the  mastoid  cells  and  fatal 
sinus  thrombosis  are  uncommon.  Paracentesis  cannot  prevent  these  com- 
plications and  it  is  of  merely  palliative  value  in  the  event  of  severe  pain. 
Proliferation  of  adenoid  tissue  as  a  result  of  measles  is  frequent.  The  cir- 
culatory system  is  much  less  seriously  affected  than  in  scarlet  fever.  The 
development  of  a  valvular  lesion  as  the  result  of  endocarditis  or  pericarditis 
is  of  rare  occurrence. 

The  nervous  system  is  markedly  affected  in  severe  cases  of  measles. 
Somnolence  and  delirium  are  not  uncommon  during  the  period  of  high 
fever.  General  convulsions  unassociated  with  spasmophilia,  are  less  fre- 
quent. Occurring  during  the  height  of  the  eruption  they  tend  to  an  unfavor- 
able prognosis.  Very  occasionally  a  purulent  meningitis  ensues,  but  more 
frequently  a  tuberculous  meningitis  is  seen  during  convalescence  or  even 
develops  months  later.  A  few  cases  of  neuritic  paralysis  have  been  reported. 

Aside  from  the  pulmonary  complications  of  measles  the  coincident 
appearance  of  diphtheria  gives  the  greatest  concern  to  the  physician.  The 
mucous  membranes  of  the  respiratory  tract  in  measles  are  as  susceptible  to 
the  diphtheria  bacillus  as  they  are  to  every  other  infecting  organism.  Dur- 
ing diphtheria  epidemics  this  complication  is  especially  to  be  dreaded  but 
it  is  quite  common  even  in  ordinary  times.  It  is  the  more  important  that 
the  physician  should  recognize  this,  because  the  diphtheritic  invasion  often 
occurs  not  in  the  pharynx,  but  in  the  larynx,  and  the  bronchi,  causing  "mea- 
sles croup."  The  occurrence,  on  the  other  hand,  of  hoarseness,  and  laryn- 
geal  stenosis  in  uncomplicated  measles  may  readily  obscure  the  diagnosis. 
Tfce  differentiation  of  these  symptoms  as  mere  manifestations  of  measles, 
from  the  similar  consequences  of  a  superimposed  diphtheria  offers  great 
difficulty,  when  there  is  no  membrane  in  the  throat.  To  await  the  report 
of  bacteriologic  findings  consumes  time  valuable  for  treatment. 

Complicating  measles  diphtheria  is  peculiar  in  the  rapidity  of  its  spread 
from  the  larynx  to  the  smaller  bronchi  causing  death  in  a  short  time.  If 
intense  hoarseness  alone  is  present  arid  if  this  is  relieved,  when  the  rash 
appears  there  is  no  great  cause  for  anxiety  since  this  symptom  is  very  com- 
mon in  early  measles,  while  complicating  diphtheria  usually  appears  at  a 
later  period.  If,  however,  there  is  marked  aphonia  and  laryngeal  stenosis 
growing  more  serious  during  the  florid  stage,  it  is  safe  to  conclude  that 
diphtheria  is  present  even  though  the  pharynx  is  entirely  clear.  Indeed, 
laryngeal  diphtheria  should  always  be  suspected  when  increasing  hoarse- 
ness and  stenosis  appear  after  the  eruption  of  the  exanthem.  In  such  cases 
a  large  dose(20,000 1.U.)of  diphtheria  antitoxin  should  be  given  immediately 
and  repeated  in  twenty-four  hours.  In  fact,  the  dose  of  the  antitoxin  should 
be  larger  than  would  be  given  in  primary  diphtheria  because  experience 
shows  that  patients  with  measles  have  a  remarkably  low  resistance  to 
diphtheria.  Even  in  later  childhood,  death  may  result  in  two  or  three  days 
from  the  development  of  the  stenosis.  To  wait  until  the  stenosis  is 


THE  ACUTE  INFECTIOUS  DISEASES  613 

grave  and  until  all  diagnostic  doubts  are  removed  is  to  be  too  late.  Intu- 
bation and  tracheotomy  are  useless  then  because  membrane  formation  has 
occurred  in  the  bronchioles.  In  fact  intubation  and  tracheotomy  should 
be  delayed  as  long  as  possible,  since  the  mucous  membranes  are  extremely 
vulnerable  during  measles  and  tend  to  necrosis:  Moreover  with  a  severe 
grade  of  inflammation  of  the  larynx  and  trachea  in  patients  with  measles  a 
fibrinous  exudate  may  develop,  which  is  not  diphtheritic,  but  due  to  strep- 
tococcic  or  diplococcic  infection.  To  be  safe,  however,  these  cases  may 
wisely  be  given  antitoxin. 

The  lowered  resistance  of  the  organism  during  measles  also  becomes 
evident  in  the  frequent  liability  to  tuberculosis  as  a  sequel.  The  fact, 
established  by  Preisich  and  von  Pirquet,  that  the  cutaneous  tuberculin 
reaction  is  temporarily  lacking  during  the  florid  stage  of  the  eruption  veiy 
probably  means,  that  the  organism  is  without  protection  against  tubercle 
bacilli  and  their  toxins  at  this  time.  So,  also,  it  satisfactorily  explains  the 
fact  that  an  inactive  tuberculous  lesion  often  becomes  active  during  mea- 
sles. As  a  result,  a  demonstrable  tuberculosis  of  the  bronchial  nodes,  or 
at  the  hilus  (Fig.  162)  or  even  a  miliary  dissemination  may  occur.  A  pre- 
existing active  tuberculosis  is  often  aggravated.  It  may  also  be  understood 
how  it  is  that  with  a  lymphatic  diathesis  after  measles,,  signs  of  scrofula, 
phlyctenule,  enlargement  of  the  lymph  nodes  and  cutaneous  tuberculides 
appear  since  scrofula  represents  the  reaction  of  a  lymphatic  diathesis  to 
tuberculosis.  An  unexplained  continuous  fever  following  measles  must 
arouse  suspicion  at  once,  that  a  quiescent  tuberculous  process  has  been 
stirred  to  activity.  The  frequently  protracted  broncho-pneumonias  of  mea- 
sles are,  as  a  rule  wrongfully  suspected  of  being  of  a  tuberculous  character. 

The  diagnosis  of  measles  is  readily  made  in  the  great  majority  of  cases 
and  offers  fewer  difficulties  than  in  scarlet  fever.  The  febrile  prodromal 
stage,  the  catarrh  of  the  upper  air  passages  and  conjunctiva,  the  Koplik's 
spots  and  the  typical  exanthem  hardly  permit  an  error  in  the  great  majority 
of  cases. 

The  eruption  alone  cannot  be  considered  conclusive  evidence  since  many 
other  diseases  cause  similar  skin  conditions  which  must  be  differentially 
excluded. 

A  severe  papular  eruption  may  resemble  variola  for  a  day  or  two,  but 
after  that  these  two  exanthemata  develop  very  differently.  In  small-pox, 
moreover,  the  temperature  falls  when  the  eruption  appears;  in  measles,  on 
the  contrary  it  rises.  Scarlet  fever  hardly  ever  causes  any  confusion,  since 
the  eruption  is  much  finer.  Confluent  measles  may  seem  to  resemble  scar- 
let fever  upon  superficial  examination  but  areas  can  always  be  found  espe- 
cially on  the  arms  and  legs,  where  the  large  spotted  measles  rash  persists. 
Furthermore,  scarlet  fever  has  no  catarrhal  prodromata  but  instead  exhib- 
its a  severe  angina,  a  strawberry  tongue,  etc. 

Rubella  is  very  similar  to  rubeola.  The  eruption,  however,  is  paler  and 
more  minute,  the  Koplik's  spots  are  absent  and  the  catarrh  and  fever  are 
slight.  Infectious  erythema  is  less  likely  to  cause  confusion.  In  this  dis- 
order, also  the  catarrhal  stage  is  lacking  and  the  exanthem  is  character- 


614  TEXT-BOOK  OF  PEDIATRICS 

istically  confluent  on  the  flexor  surfaces  of  the  arms.  In  sepsis  multiform 
eruptions,  among  them  sometimes  a  rash  resembling  measles,  may  appear, 
but  associated  symptoms  make  the  differentiation  easy.  Roseola  syphilit- 
ica,  if  the  eruption  is  sudden  and  severe  may  temporarily  resemble  mea- 
sles. In  diseases  of  the  la  grippe  order,  rubeoloid  rashes  occasionally 
occur  and  may  lead  to  error  on  account  of  the  coincident  presence  of  ca- 
tarrhal  conditions.  The  exanthem,  however,  is  more  transient  and  irregu- 
lar than  in  measles  and  Koplik's  sign  is  never  present. 

Following  vaccination  and  in  the  disturbances  of  nutrition  of  infancy 
erythemata  resembling  measles  are  not  infrequently  seen,  but  these  do  riot 
affect  the  mucous  membranes.  Toxic  erythemata  also  occurring  after 
serum  injection  or  following  the  use  of  certain  drugs  are  very  likely  to  lead 
to  temporary  error.  The  question  they  raise  however,  is  soon  determined 
by  the  variability  and  atypical  forms  of  these  eruptions,  by  the  fact,  that 
urticarial  and  scarlatinoid  types  will  develop  side  by  side,  and  by  the  rarity 
of  their  spread  over  the  entire  body.  In  doubtful  cases  the  presence  or 
absence  of  Koplik's  sign  characteristic  only  of  measles,  the  recognition  of 
the  early  febrile  stage,  the  occurrence  of  the  catarrhal  prodromata  and  con- 
junctivitis, the  regular  spread  of  the  rash,  the  diazo-reaction,  and  the  blood 
findings  (leucopenia  suggesting  measles  or  the  serum  exanthemata,  a  neu- 
trophilic  leucocytosis  and  eosinophilia  favoring  scarlet  fever)  will  have  due 
weight.  The  diagnosis  may  be  assisted  by  the  definite  incubation  period 
and  by  the  knowledge  of  other  neighborhood  cases.  The  absence  of  any 
possible  source  of  infection  is  also  to  be  considered. 

The  prognosis  may  be  made  with  some  degree  of  assurance  at  the  begin- 
ning of  the  attack  since  the  course  of  measles  is  almost  always  the  classical 
one.  The  insidious,  the  unsuspected  element  so  usual  in  scarlet  fever  is 
lacking  in  measles.  In  strong  healthy  children  of  over  three  years  of  age  a 
favorable  prognosis  may  be  almost  invariably  made.  The  disease  holds 
more  danger  it  is  true,  for  younger  children  and  especially  for  the  feeble 
and  rickitic,  who  so  often  die  of  broncho-pneumonia.  A  coincident  infec- 
tion with  diphtheria  is  dangerous  at  any  age. 

During  the  convalescence  from  measles  of  children  who  have  suffered 
with  tuberculosis,  in  whom  nothing  more  than  a  positive  tuberculin  reac- 
tion gives  evidence  of  infection,  the  recrudescence  of  tuberculous  disease 
or  the  possible  development  of  miliary  tuberculosis  is  to  be  reckoned  with. 

An  abortive  or  cyanosed  eruption  suggests  an  unfavorable  prognosis 
and  so  does  the  coincidence  of  severe  bronchitis.  A  favorable  outcome  is 
prejudiced  by  cold  weather,  by  bad  environment,  or  by  want  of  care. 

Prophylaxis  should  attempt  to  guard  children  under  three  or  four  years 
of  age  from  contagion.  If  the  patient  is  isolated  at  the  beginning  of  the 
prodromal  stage,  it  is  often  possible  to  prevent  the  spread  of  the  contagion 
to  other  children  in  the  family.  Isolation  after  the  eruption  has  appeared 
is  always  too  late.  Since  every  person  must  have  measles  at  one  time  or 
another,  it  seems  proper  not  to  protect  strong  healthy  children  of  four  years 
or  more,  from  the  possibility  of  contagion.  The  weak,  the  sickly  and  espe- 
cially the  tuberculous  should  always  be  shielded.  Day  nurseries  and  kin- 


THE  ACUTE  INFECTIOUS  DISEASES  615 

dergartens  often  form  dangerous  nests  of  infection  during  an  epidemic  and 
should  be  avoided  and  closed  at  such  a  time.  The  closing  of  the  public 
schools  is  not  justified.  Only  in  exceptional  instances  does  the  summer 
vacation  interrupt  the  course  of  an  epidemic.  This  is  shown  by  the  curve 
of  Basel  for  the  year  1884.  (See  Fig.  156.)  During  the  prevalence  of  the 
disease  very  young  children  should  be  kept  away  from  public  places. 

The  disinfection  of  living  rooms  and  their  contents  after  measles  is 
superfluous  and  useful  only  for  the  prevention  of  secondary  infections,  as 
pneumonia,  etc.  Even  a  room  occupied  but  a  day  before  by  a  measles 
patient-  may  be  turned  over  to  a  person  who  has  not  had  the  disease  with- 
out any  danger. 

Treatment  of  mild  cases  should  be  expectant.  Upon  the  first  suspicion 
of  the  disease,  the  patient  should  be  put  to  bed  in  an  airy,  warm  room 
which  proper  provision  for  atmospheric  moisture  is  made.  Strong  light 
should  be  avoided,  but  semi-darkness  is  necessary  only  in  event  of  severe 
photophobia.  The  complete  darkness,  formerly  much  in  vogue,  has  no 
advantages  and  interferes  with  sleep  at  night.  During  the  febrile  period  the 
diet  should  be  in  fluid  form  and  readily  digestible.  In  infancy,  it  should  con- 
sist of  milk  arid  gruels.  If  there  is  any  tendency  to  diarrhoea,  the  milk  should 
be  reduced  and  the  calories  supplied  by  the  addition  of  dextri-maltose. 
Older  children  may  be  allowed  milk,  milk  toast,  barley  soup,  gruels,  fruit- 
juices,  etc.  In  obstinate  anorexia,  which  is  so  frequently  observed,  it  will 
suffice  to  give  large  quantities  of  water.  Before  the  appearance  of  the  erup- 
tion large  draughts  of  hot,  dilute,  sweetened  tea  may  be  given,  while  the 
patient  is  kept  well  covered  in  bed,  with  the  intent  of  favoring  the  full  erup- 
tion of  the  exanthem.  If  the  rash  is  delayed  a  hot  bath  is  to  be  recom- 
mended. Ordinarily  no  active  measures  are  required  so  far  as  the  fever  is 
concerned.  In  extreme  pyrexia,  cold  compresses  or  an  ice-cap  to  the  head 
and  light  bed  covering  will  suffice.  The  laity  is  quite  justified  in  its  fear  of 
cooling  measures,  which  if  not  properly  controlled  may  certainly  do  harm. 
Considering  the  short  duration  of  the  fever  they  are  not  indispensible. 

The  mucous  membranes  should  be  the  chief  concern.  The  exercise  of 
extreme  cleanliness,  the  avoidance  of  unnecessary  attendants  and  especially 
of  contact  of  those  who  suffer  with  catarrhal  affections,  are  matters  of  prime 
importance.  Patients  with  measles  who  develop  grave  bronchitis  or  bron- 
cho-pneumonia, should  not  be  kept  in  the  same  room  with  other  patients 
who  are  free  from  these  complications. 

A  dilute  solution  of  acetate  of  lead  is  often  useful  in  severe  conjunctivi- 
tis. (A  teaspoonful  of  lead  acetate  to  one  litre  of  cold  water.)  Applications 
of  it  should  be  changed  every  few  minutes  for  a  period  of  one-half  hour, 
several  times  a  day.  The  purulent  secretion  should  be  removed  from  the 
lids  by  a  cotton  probang  moistened  in  a  tepid  boric  acid  solution.  The 
nares  should  be  frequently  and  thoroughly  cleansed  of  all  secretion.  Lano- 
lin or  a  one  per  cent,  ammoniated  mercury  ointment  may  be  used  in  the 
nostrils,  when  the  inflammation  is  marked.  Children  who  are  old  enough 
should  rinse  the  mouth  frequently  with  warm  water  in  which  a  little  borax 
has  been  dissolved.  With  younger  children  it  must  suffice  to  give  them 


616  TEXT-BOOK  OF  PEDIATRICS 

water  to  drink  after  each  feeding.  In  severe  stomatitis  a  spray  of  hydrogen 
peroxide  (2  per  cent.)  is  useful.  Aphthae  and  ulcers  may  be  painted  with  a 
1  per  cent,  solution  of  potassium  permanganate  and  later  with  a  2  per  cent, 
solution  of  silver  nitrate  or  with  a  dusting  powder  of  iodoform. 

If  the  cough  is  very  annoying  but  the  bronchi  are  free  from  excessive 
mucus  a  desirable  quieting  effect  may  be  obtained  with  codein.  For  chil- 
dren of  one  year  codein  sulphate  in  the  proportion  of  gram  0.03  to  100  c.  c. 
of  water  and  for  children  of  five  years  in  the  proportion  of  gm.  0.1  (grs.  ii) 
to  a  similar  quantity  of  water,  may  be  given  in  doses  of  5-10  c.  c.  The 
croup  kettle  gives  great  relief  in  cases  of  hoarseness,  pseudocroup,  and 
stenosis.  By  this  or  other  means  a  thorough  moistening  of  the  air  of  the 
apartment  should  be  secured.  Children  of  sufficient  age  may  be  allowed  to 
inhale  salt  vapor.  In  laryngitis  cold  applications  about  the  neck  may  prove 
useful  and  sometimes  stenosis  may  be  relieved  by  leeches  applied  over  the 
sternal  notch.  If  laryngeal  diphtheria  is  even  suspected  an  injection  of 
4000  units  of  serum  should  be  given  at  once. 

During  the  stage  of  the  exanthem  mild  bronchitis  requires  no  treatment. 
The  more  severe  grades  of  bronchitis  with  fine  rales  or  a  broncho-pneumo- 
nia should  be  treated  in  the  usual  way. 

In  measles  the  application  of  cold  packs  or  cold  baths  requires  careful 
consideration.  The  bad  effects  of  this  practice  are  seen,  especially  in  younger 
children  whenever  the  skin  fails  of  brisk  reaction  both  as  to  warmth  and 
color.  Cold  applications  in  measles  are  sufficiently  unpopular  among  the 
laity,  due  to  the  idea  that  the  rash  may  "strike  inward"  a  supposition  not, 
without  a  measure  of  truth.  Warm  baths  34°-32°  C.  (95°-90°  F.)  on  the 
other  hand,  are  without  danger.  If  the  skin  is  cyanotic,  the  extremities 
cold  in  spite  of  the  high  fever,  and  the  rash  but  poorly  developed  a  short 
hot  bath  at  37°  C.  (98.6°  F.),  rapidly  raised  to  40°-41°  C.  (104°-105°  F.), 
often  brings  the  rash  out  and  improves  the  circulation.  A  similar  bath 
followed  by  a  cold  douche,  or  Heubner's  mustard  pack  (see  page  372)  are 
indicated  in  bronchiolitis  or  broncho-pneumonia.  Under  these  conditions 
such  stimulants  as  caffein  and  camphor  may  be  necessary  to  combat  car- 
diac weakness  and  vasomotor  paralysis. 

It  is  best  to  keep  every  child  who  has  even  an  ordinary  attack  of  mea- 
sles in  bed  for  eight  days  after  the  fall  of  the  fever.  After  this  interval  the 
child  may  be  permitted  to  sit  up  and  very  soon  or  within  a  week  or  so, 
according  to  circumstances,  season,  and  the  age  of  the  child  to  go  out  of 
doors.  Should  convalescence  be  delayed,  or  the  catarrhal  conditions  prove 
obstinate  a  visit  to  the  country  may  be  indicated.  Such  an  expedient  is 
particularly  desirable  when  variations  of  temperature,  with  or  without  a 
positive  tuberculin  reaction,  lead  one  to  suspect  the  reactivation  of  an  old 
tuberculous  focus. 

RUBELLA 

(GERMAN  MEASLES,  ROTELN) 

Although  the  distinctive  character  of  rubella  has  been  discussed  for 
several  centuries,  it  has  been  generally  recognized  as  a  specific  infection  for 


617 

some  thirty  years  and  its  identity  is  now  denied  only  by  those  who  have 
never  seen  an  epidemic. 

Rubella  may  be  defined  as  an  extremely  benign  contagious  disease 
characterized  by  a  mild  measles-like  eruption  upon  the  appearance  of  which 
the  initial  catarrhal  symptoms,  fever  and  other  general  symptoms  disappear. 

The  causative  organism  and  its  port  of  entry  are  still  unknown.  The 
transmission  of  the  disease  is  usually  direct  from  one  person  to  another 
and  only  upon  close  contact.  It  is  possible  that  in  exceptional  cases,  the 
disease  may  be  carried  by  a  third  person  or  by  objects  handled.  Sporadic 
cases  are  not  common.  The  disease  usually  appears  as  a  local  epidemic 
and  most  commonly  in  the  spring.  Such  an  epidemic  frequently  continues 
for  several  months  without  attaining  any  great  severity.  It  may  put  in  an 
appearance  at  irregular  intervals  after  an  absence  of  many  years.  The 
writer  has  had  the  opportunity  to  observe  two  such  epidemics. 

Individual  predisposition  is  much  less  marked  than  in  measles.  If  how- 
ever, the  disease  develops  in  an  institution,  school  or  asylum,  as  it  often 
does,  one-half  or  more  of  the  inmates  are  commonly  attacked. 

Children  are  especially  predisposed  between  the  ages  of  three  and  twelve 
and  most  markedly  within  school  age.  The  disease  is  often  to  be  seen  how- 
ever, in  late  infancy.  It  is  even  said  to  occur  congenitally  by  transmission 
from  the  affected  mother. 

It  is  contagious  even  at  the  close  of  the  incubation  period,  the  contagion 
reaching  its  height  at  the  onset  of  the  eruption  and  disappearing  as  the 
eruption  fades.  The  virus  is  of  brief  viability. 

The  incubation  period  covers  usually  from  seventeen  to  twenty-one 
days  and  rarely  falls  within  two  weeks.  The  author  has  usually  seen  sec- 
ondary cases  develop  within  infected  families  in  from  eighteen  days  to 
three  weeks. 

Prodromal  symptoms  are  usually  lacking.  Occasionally  the  appearance 
of  the  rash  may  be  preceded  by  general  malaise,  sore  throat,  slightly  red- 
dened conjunctivas,  coryza,  and  even  slight  rises  of  temperature.  These 
symptoms  are  so  slight,  however,  that  the  physician  only  hears  about  them 
when  he  is  called  in  on  account  of  the  rash.  Most  cases  are  so  mild  that 
they  are  seen  only  in  family  practice  and  so  prominent  a  clinician  as  Henoch 
had  never  met  definite  epidemic  cases. 

Symptoms. — 'The  exanthem  is  usually  the  first  noticeable  sign  of  the 
disease.  It  first  appears  on  the  bridge  of  the  nose,  around  the  ears,  and 
over  the  forehead  and  cheeks  and  on  the  hairy  scalp.  It  spreads  rapidly 
and  may  cover  the  entire  body  in  half  a  day.  Small  flat  or  slightly  raised 
light  red  spots  appear,  the  size  of  a  pinhead  and  rapidly  increase  to  the 
size  of  a  lentil.  They  are  clearly  circumscribed  and  are  usually  round  or 
oval  in  form.  Their  outline  is  not  so  jagged  and  irregular,  nor  are  they  so 
large  or  of  so  dark  a  red  nor  so  prominently  raised  as  the  papules  of  mea- 
sles. By  way  of  further  comparison  the  individual  spots  are  all  of  the  same 
size;  they  are  equally  distributed  and  are  hardly  ever  confluent  being  sepa- 
rated by  much  clear  space.  In  the  latter  respect  they  have  a  similarity 
to  scarlet  fever,  although  the  spots  are  larger  than  in  that  disease.  Upon 


618  TEXT-BOOK  OF  PEDIATRICS 

the  cheek  only  the  eruption  sometimes  appears  in  a  fine  network.  At  the  be- 
ginning the  face  looks  congested  and  remarkably  red,  so  that  during  an 
epidemic  the  teacher  is  often  able  to  make  the  diagnosis  and  send  the 
child  home. 

The  eruption  is  often  so  pale  that  it  is  overlooked.  The  individual  spots 
will  at  first  disappear  upon  pressure,  but  later  they  will  occasionally  leave 
slight  pigmentation,  which  is  never  so  marked  as  it  is  in  measles.  Some- 
times a  fine  dust-like  desquamation  of  the  epidermis  is  seen. 

On  the  body,  the  eruption  is  often  most  distinct  at  any  point  on  which 
the  clothing  rubs.  Generally  speaking  the  face,  back  and  exterior  surfaces 
of  the  limbs  are  most  markedly  affected.  The  eruption  is  rarely  distributed 
uniformly  over  all  parts  of  the  body  at  one  time.  It  appears  usually  in 
crops,  the  eruption  upon  the  head  having  begun  to  fade  by  the  time  it  de- 
velops upon  the  trunk  and  this,  in  turn,  fading  as  the  extremities  become 
involved.  Frequently  large  areas  of  the  body  are  spared.  The  rash,  in  any 
one  spot,  only  continues  in  full  bloom  for  a  day  or  two.  It  disappears 
rapidly,  entirely  passing  away  in  from  two  to  four  days.  The  author's 
observations  •  suggest  that  successive  relapses  occasionally  develop,  even 
into  the  second  week.  Thus  it  is  seen  that  rubella  most  closely  resembles 
the  eruption  of  measles  excepting  that  it  is  paler  and  less  dense.  Some- 
times the  rash  is  very  indistinct,  the  margins  of  the  spots  leaving  a  washed- 
out  appearance  and  being  connected  with  each  other  by  small  bridges  give 
the  skin  a  mottled  appearance.  Very  rarely  the  rash  is  so  fine  as  to  resem- 
ble scarlet  fever,  showing  this  quality  in  certain  areas  only,  as  over  the 
chest  or  upon  the  thighs.  In  the  course  of  epidemics  the  author  has  observed 
that  no  cases  have  occurred  in  which  the  entire  exanthem  was  scarlatinal 
in  type.  Such  cases  would  appear  to  be  properly  classed  with  the  so-called 
fourth  disease.  Sometimes  the  eruption  takes  on  an  urticarial  form. 

The  affection  of  the  mucous  membranes  is  unimportant.  A  slight  red- 
dening of  the  conjunctiva,  an  insignificant  coryza,  some  sneezing,  a  mild 
hyperemia  of  the  pharynx  and  tonsils,  a  swelling  of  the  lymph  follicles  of 
the  soft  palate  and  occasionally  fine  scattered  hemorrhages  in  the  mucous 
membrane  over  these  areas  are  observed  upon  the  appearance  of  the  rash, 
or  even  a  few  days  before  the  exanthem  develops.  These  symptoms  are  so 
uncertain  and  so  frequently  occur  ab  initio,  that  they  have  no  diagnostic 
value.  It  is  an  important  point,  however,  that  Koplik's  spots  are  always 
absent.  In  some  cases  there  is  slight  hoarseness  and  cough,  but  bronchial 
rales  are  almost  always  lacking. 

The  swelling  of  the  superficial  lymph  nodes  is  an  important  and  a  con- 
stant symptom.  The  nodes  over  the  mastoid  process  and  in  the  occipital 
and  cervical  regions,  particularly,  will  usually  swell  before  the  exanthem 
appears,  so  that  adults  and  children  of  observing  years  will  complain  of 
their  painful  and  visible  swelling  some  two  to  four  days  before  the  develop- 
ment of  the  rash  and  will  come  to  the  physician  in  consequence.  These 
nodes  may  reach  from  the  size  of  a  bean  to  that  of  a  hazel-nut.  They  are  at 
times  tender  upon  pressure  and  they  disappear  in  a  week  or  two.  Fre- 
quently the  axillary  and  inguinal  nodes  are  also  enlarged. 


THE  ACUTE  INFECTIOUS  DISEASES  619 

Recently  rubella  sine  eruptione  has  been  described  (Koplik).  It  has  been 
recognized  during  epidemics  of  the  disease  by  the  occurrence  of  swelling  in 
these  groups  of  lymph  nodes  without  other  symptoms. 

The  temperature  may  show  only  occasional  minor  rises  during  the  entire 
course  of  the  disease.  In  the  prodromal  stage  it  may  reach  38°-38.5°  C. 
(100°-101°  F.)  and  during  the  first  day  of  the  eruption  even  39°  C.  (102°  F.) 
but  it  rarely  goes  higher.  Then  it  falls  rapidly,  even  though  the  eruption 
persists.  Many  cases  run  their  entire  course  without  fever. 

The  blood  shows  no  essential  changes  in  the  number  of  leucocytes  at 
the  onset  of  the  eruption. 

The  general  health  is  very  slightly  affected  and  in  a  major  number  of 
cases  is  not  disturbed.  It  may  almost  be  said  that  the  only  actual  symptom 
of  the  disease  is  the  eruption.  In  fact,  the  physician  sees  very  few  of  these 
cases  and  these  few  only  because  of  the  fear  that  they  may  be  measles  or 
scarlet  fever.  When  cases  follow  one  another  in  the  same  family  the  parents 
consider  it  unnecessary  to  call  a  physician.  Very  rarely  high  fever,  a  marked 
angina  or  bronchitis  make  a  more  serious  clinical  picture,  a  development 
more  frequent  among  adults  than  in  children. 

The  lungs,  heart,  circulation,  brain  or  meninges  are  not  involved  in  this 
disease.  In  exceptional  cases  a  transient  nephritis  has  been  observed. 

Serious  symptoms  or  complications  such  as  necrotic  angina,  severe  ne- 
phritis, marked  desquamation  of  the  skin,  inflammation  of  the  joints  bron- 
cho-pneumonia, etc.,  frequently  ascribed  to  this  disease,  certainly  indicate 
its  confusion  with  scarlet  fever,  measles  or  some  other  infectious  disease. 

It  follows  that  the  course  of  rubella  is  almost  without  exception  mild 
and  of  brief  duration.  It  may  be  considered  the  most  benign  of  all  known 
infectious  diseases. 

Diagnosis. — Isolated  cases  may  be  very  difficult  or  even  impossible  of 
diagnosis.  During  an  epidemic  the  diagnosis  is  an  easy  matter.  Added  to 
the  peculiar  exanthem,  the  typical  swelling  of  the  occipital  lymph  nodes, 
the  absence  of  any  marked  affection  of  the  upper  air  passages  and  the  neg- 
ligible disturbance  of  the  general  health,  assist  in  the  recognition  of 
the  disease.  As  in  all  the  exanthemata,  a  diagnosis  cannot  be  made  from 
the  eruption  alone,  but  all  other  factors  and  symptoms  must  be  taken  in- 
to consideration. 

Rubella  resembles  mild  forms  of  measles  very  closely  and  is  quite  often 
confused  with  it.  Many  physicians  formerly  regarded  the  disease  as  merely 
an  attenuated  form  of  measles.  However,  the  exanthem  of  measles  is 
usually  more  distinct,  of  deeper  red,  more  elevated  above  the  surface  of 
the  skin,  more  pronounced  and  diffuse,  while  the  attending  fever  is  higher 
and  the  involvement  of  the  conjunctivse  and  the  upper  air  passages  is  more 
marked.  The  exanthem  of  measles  in  feeble  and  anemic  children  is  often 
indistinct  and  undeveloped  and  therein  resembles  rubella  more  nearly  than 
any  other  condition.  The  Koplik's  spots  always  definitely  suggest  measles 
and  contraindicate  rubella.  Nevertheless  doubtful  cases  always  occur, 
which  are  differentiated  only  by  the  nature  of  the  prevailing  epidemic. 
Strangely  enough  epidemics  of  rubella  and  of  measles  often  follow  each  other. 


620  TEXT-BOOK  OF  PEDIATRICS 

If  the  length  of  the  incubation  period  can  be  determined  it  assists  in  the 
differentiation  of  the  two  diseases,  since  that  of  rubella  is  at  least  fourteen 
days  while  that  of  measles  is  but  ten  or  eleven  days.  Further,  the  absence 
of  prodromes  suggests  rubella.  So  also,  does  the  fact  that  the  patient  has 
already  had  measles,  or  contracts  this  disease  at  a  later  date. 

In  rubella,  the  diazo-reaction  in  the  urine  is  said  to  be  lacking.  The 
von  Pirquet  cutaneous  tuberculin  reaction  does  not  fail,  as  it  does  in  measles. 

The  characteristic  description  of  the  disease  should  not  permit  of  its 
very  frequent  confusion  with  scarlet  fever. 

An  exanthem  resembling  rubella  occasionally  follows  an  injection  of 
serum  or  the  use  of  certain  drugs  or  the  practice  of  vaccination.  Similar 
eruptions  may  occur  in  the  new-born  or  in  infants  suffering  with  disturb- 
ances of  nutrition,  in  cases  of  la  grippe  and  in  various  other  infectious 
diseases.  At  times  these  imitative  conditions  may  demand  that  all  the 
circumstances  surrounding  them  be  taken  into  consideration  (vide  mea- 
sles p.  613). 

In  so  benign  a  disease  special  prophylaxis  is  unnecessary.  Isolation 
should  be  enforced  only  in  cases  in  which  the  diagnosis  is  not  clear.  Feeble 
and  rickitic  infants  must  be  guarded  against  infection  if  possible. 

Treatment. — No  special  treatment  is  required.  If  there  is  fever,  rest 
in  bed  and  a  liquid  diet  should  be  ordered.  Children  of  school  age  should 
be  kept  at  home,  for  the  protection  of  other  pupils  for  eight  or  ten  days; 
but  feeling  well  and  in  good  weather,  they  may  be  allowed  to  go  out  of  doors. 

INFECTIOUS  ERYTHEMA 

Infectious  erythema  is  a  well  defined  infectious  disease,  which  runs  its 
course  without  any  serious  disturbance  of  the  general  health.  Its  most 
important  symptom  is  a  large  macular  and  frequently  confluent  exanthem 
covering  the  face  and  the  extensor  surfaces  of  the  limbs.  It  resembles  mea- 
sles or  a  multiforme  exudative  erythema.  Many  other  names,  as  local  ru- 
bella, megalerythema  epidemicum,  etc.,  have  been  given  to  it. 

The  disease  has  been  described  only  in  recent  years.  It  was  first  ob- 
served, on  various  occasions,  in  Gratz  and  later,  in  other  parts  of  Germany. 
An  extensive  epidemic  of  it  was  seen  by  the  author  in  Basel  in  the  year  1903. 
Almost  all  writers  now  agree  that  it  is  disease  entity. 

Sporadic  cases  occasionally  appear  and  frequently  fail  of  diagnosis. 
Commonly,  however,  the  disease  occurs  in  small  epidemics  confined  with- 
in an  institution  or  a  single  school.  Spring  is  the  season  in  which  such 
outbreaks  are  usually  seen.  They  are  said  to  occur  coincidently  with  mea- 
sles and  rubella. 

Most  cases  develop  at  an  early  age.  The  youngest  patient  observed  was 
at  one  year  and  the  oldest  at  twenty  years  of  age.  The  method  of  conta- 
gion is  not  definitely  known.  Direct  transmission  seems  infrequent  although 
it  has  certainly  been  noted  (Pfaundler).  According  to  most  reports  the 
period  of  incubation  varies  from  seven  to  fourteen  days.  It  seems  fairly 
constant,  since  the  writer  has  seen  two  children  in  each  of  two  families  and 


THE  ACUTE  INFECTIOUS  DISEASES  621 

three  children  in  a  third  household  attacked  at  the  same  time  without  be- 
ing able  in  any  one  instance  to  trace  the  source  of  infection. 

Restlessness,  general  malaise,  and  slight  sore  throat  occasionally  mark 
the  prodromal  stage,  which,  however,  is  usually  absent. 

The  exanthem  is  generally  the  first  sign  of  illness.  It  appears  first  and 
most  distinctly  on  the  face  and  the  extremities.  On  the  cheeks  large  bright 
red  and  markedly  raised  spots  which  often  resemble  variola  are  seen.  These 
enlarge  rapidly  becoming  confluent  within  a  short  time.  During  this  devel- 
opment the  central  portion  of  these  plaques  is  often  flattened  and  becomes 
paler.  The  cheeks  show  a  marked  degree  of  congestion,  being  very  red, 
hot  and  infiltrated.  A  sharp  demarcation  from  the  normal  skin  at  the 
irregular,  raised  edges  of  the  exanthem,  especially  upon  the  chin  and  about 
the  ears  is  quite  characteristic.  The  region  of  the  nose  and  mouth  frequently 
remains  clear;  the  forehead  is  usually  affected  but  there  the  rash  is  lighter 
in  color.  Besides  the  face,  the  extensor  surfaces  of  the  arms  from  the  shoulders 
to  the  fingers  are  most  frequently  and  markedly  involved.  The  rash  is 
also  definite  over  the  buttocks  and  upon  the  legs,  where  the  selection  of  the 
extensor  over  the  flexor  surfaces  is  not  so  great.  The  eruption  usually 
spreads  symmetrically  over  both  sides  of  the  body.  Occasionally,  it  begins 
on  the  limbs,  on  the  shoulders,  or  the  buttocks  in  the  form  of  raised  red 
spots,  which  feel  hot  and  spreading  become  confluent  in  geographic,  cres- 
centic  or  garland-like  figures.  The  exanthem  is  exceptionally  most  marked 
on  the  flexor  surfaces  of  the  arms,  becoming  confluent  and  covering  large 
areas,  gradually  diminishing  toward  the  extensor  surfaces  to  small  rube- 
olar  or  urticarial  spots.  The  trunk  usually  remains  free  from  the  rash  or 
shows  a  slighter,  paler  and  more  mottled  eruption  within  the  first  two  or 
three  days. 

The  rash  often  takes  on  a  cyanotic  or  brownish  tint.  It  usually  disap- 
pears rapidly  and  occasionally  leaves  a  slight  pigmentation.  It  is  followed 
by  no  distinct  desquamation. 

The  duration  of  the  eruption  is  usually  about  a  week.  Not  infrequently 
a  brief  recrudescence  is  seen  in  some  areas  after  the  initial  rash  has  begun 
to  disappear,  which  is  due  to  such  external  causes  as  perspiration,  irrita- 
tion of  the  clothing,  etc. 

During  the  period  of  eruption  other  manifestations  always  subside  and 
entirely  disappear.  Frequently  there  is  a  complete  absence  of  fever  during 
the  entire  course  of  the  disease.  At  times,  and  especially  at  the  onset  of 
the  attack,  a  subfebrile  temperature  of  38°  to  39°  C.  (100°-102°  F.)  is  re- 
corded, but  even  this  minor  rise  is  uncommon.  General  disturbances  of 
any  degree  of  severity  hardly  ever  occur.  There  may  be  a  measure  of  rest- 
lessness, disturbed  sleep,  some  itching,  a  painful  tension  of  the  skin  over 
the  face  and  occasionally  a  sore  throat.  A  reddening  of  the  conjunctiva 
and  of  the  pharyngeal  mucosa  may  be  present,  the  latter  resulting  in  cough. 
In  some  instances  at  the  onset  a  lacunar  angina  is  observed. 

A  minor  enlargement  of  the  lymph  nodes  of  the  neck  is  occasionally 
seen.  There  is  no  record  of  any  definite  complications.  The  disease  always 


622  TEXT-BOOK  OF  PEDIATRICS 

goes  on  to  recovery  and  leaves  no  after  consequences  in  its  train.  That  the 
few  fatal  cases  reported  are  true  examples  of  this  disease  is  an  open  question. 

A  diagnosis  is  readily  made  during  an  epidemic  from  the  peculiar  type 
of  the  eruption  and  the  areas  it  characteristically  affects.  It  is  very  readily 
confused  with  measles,  but  the  catarrhal  prodromes  and  the  generally  dif- 
fuse exanthem  of  the  latter  should  differentiate  it.  Koplik's  spots  are  never 
seen  in  infectious  erythema.  It  has  a  resemblance  to  rubella  only  when  the 
rash  upon  the  face  in  the  latter  infection  is  very  definite  and  confluent. 
The  eruption  in  rubella  is  never  so  pronounced  or  confluent  over  the  rest 
of  the  body  nor  is  it  localized  so  peculiarly.  Multiforme  exudative  ery- 
thema is  of  longer  duration  and  its  rash  is  more  variable,  exhibiting  the 
vesicular,  the  bullous,  or  the  urticarial  forms.  It  usually  affects  chiefly  the 
dorsal  surfaces  of  the  hands  and  feet.  It  resembles  the  epidemic  disease 
in  so  many  other  respects,  however,  that  Escherich  is  inclined  to  regard  the 
latter  as  an  abortive  form  of  muliple  erythema.  The  author  cannot  support 
this  view. 

The  disease  requires  no  treatment. 


In  1900,  Dukes  described,  a  new  form  of  contagious  exanthematous 
disease  resembling,  in  all  its  symptoms,  a  mild  scarlet  fever,  but  with  which 
it  is  not  supposed  to  be  identical.  Since  Dukes  found  it  also  non-identical 
with  either  measles  or  rubella  he  called  it  "The  Fourth  Disease." 

After  observing  several  epidemics  of  this  malady,  Dukes  describes  it  in 
the  following  detail: 

Usually  it  has  no  other  prodromes  than  a  slight  sore  throat  and  nausea. 
Within  a  few  hours  the  body  is  covered  with  a  dense  eruption  consisting  of 
very  small  punctiform  and  slightly  raised  spots  of  a  pale  red  color.  The 
lips  and  the  nose  are  not  usually  involved.  According  to  Weaver  on  the 
contrary  they  may  be  also  affected.  The  conjunctivas  and  the  pharynx 
are  reddened  and  the  cervical  lymph  nodes  are  enlarged,  but  less  markedly 
so  than  in  rubella.  No  strawberry  tongue  is  observed.  The  rash  disappears 
rapidly  and  is  followed  by  a  slight  coryza,  which  persists  for  a  week  or  two. 

At  times  a  slight  albuminuria  lasting  but  a  short  period  is  noted  as  a 
sequel.  The  general  health  is  but  slightly  or  not  noticeably  disturbed; 
the  fever  is  absent  or  slight;  convalescence  is  short  and  without  complica- 
tions. The  disease  is  contagious  for  two  or  three  weeks. 

Every  physician  frequently  meets  such  cases,  either  of  sporadic  appear- 
ance or  in  the  course  of  mild  epidemics  of  scarlet  fever  and  their  occurrence 
with  other  scarlet  fever  cases  alone  permits  of  their  recognition.  Dukes 
however,  distinguishes  this  disease  from  scarlet  fever  and  for  very  good 
reasons.  First,  and  notably  because  it  often  attacks  children,  who  have 
already  had  scarlet  fever  or  it  affects  those  who  subsequently  develop  scar- 
let fever.  Secondly,  because  it  is  always  mild  and  without  complications; 
and,  third,  because  its  incubation  period  of  from  nine  to  twenty-one  days 
is  accounted  longer  than  that  of  scarlet  fever. 

Filatow  probably  describes  the  same  disease  in  1886  under  the  name  of 


THE  ACUTE  INFECTIOUS  DISEASES  623 

rubeola  scarlatinosa,  which  he  intended  to  designate  as  a  separate  disease, 
but  not  as  a  variety  of  rubeola. 

The  longer  incubation  period  might  suggest  rubella  but  Dukes  distin- 
guishes it  from  this  disease  by  virtue  of  the  fact  that  it  frequently  affects 
those  in  later  childhood,  who  have  already  had  rubella.  Other  authors  and 
among  them  Heubner  deny  the  specificity  of  the  disease,  considering  it  an 
abortive  form  of  rubella  or  scarlet  fever.  Since  the  exanthemata  due  to 
sera  or  to  certain  drugs  show,  that  one  and  the  same  substance  may  pro- 
duce now  a  scarlatinoid  eruption,  and  again  a  rubeolar,  rubellar  or  urtica- 
rial  rash,  it  is  certainly  not  permissible  to  lay  too  much  stress  upon  the 
morphologic  form  of  an  eruption  in  drawing  distinctions  between  these 
several  diseases. 

The  writer  would  call  attention,  however,  to  the  fact  that  in  epidemics 
of  true  rubella,  cases  with  a  purely  scarlatinoid  exanthem  have  hardly  ever 
been  described.  In  the  course  of  two  large  epidemics  of  rubella,  he  has  seen 
cases  which  presented  a  rash  of  scarlatinal  character  over  small  areas,  but 
never  one  in  which  the  entire  eruption  was  of  that  type. 

With  many  other  physicians  he  has  often  seen  cases  which  ran  a  course 
similar  to  that  of  very  mild  scarlet  fever,  in  which  a  diagnosis  of  scarlet 
fever  was  nevertheless  excluded  on  account  of  existing  epidemiologic  con- 
ditions, an  epidemic  of  this  disease  having  preceded  the  present  prevailing 
malady.  These  cases  may  have  been  identical  with  "The  Fourth  Disease" 
but  the  author  cannot  establish  positive  proof  of  the  fact. 

The  discussion  concerning  the  existence  of  "The  Fourth  Disease"  is  not 
yet  closed.  The  determination  of  its  entity  can  come  alone  from  the  dis- 
covery of  a  distinct  causative  organism,  or  from  more  exact  studies  of  its 
hematology  and  serology.  Very  probably  we  shall  be  justified  in  recogniz- 
ing with  Dukes  and  Filatow  the  differentiation  of  the  Fourth  Disease  from 
scarlet  fever.  Indeed  it  is  not  impossible  that  there  are  several  scarla- 
tinal  diseases.  VARICELLA 

(CHICKEN-POX) 

Varicella  is  a  contagious  exanthematous  disease,  usually  causing  only 
slight  general  manifestations  and  characterized  by  an  eruption  of  roseolar 
spots,  some  of  which  develop  into  vesicles,  which  commonly  dry  up  with- 
out pustulation  and  healing,  usually  leave  no  scar. 

The  causative  organism  is  unknown;  apparently  it  is  not  present  in  the 
vesicles,  since,  in  contrast  to  small-pox,  vaccination  of  other  persons  with 
fluid  from  the  vesicles  has  been  unsuccessful. 

Children  up  to  the  age  of  ten  years  are  most  frequently  affected.  Dur- 
ing the  first  three  months  of  life  cases  are  uncommon,  but  even  the  new-born 
are  occasionally  affected.  After  the  tenth  year  the  number  of  cases  rapidly 
decreases.  The  disease  is  very  uncommon  in  adults.  The  author  has  seen  it, 
however,  in  a  negress  of  thirty  and  in  a  man  of  sixty.  In  both  instances 
infection  from  children  could  be  proven. 

The  predisposition  among  children  is  very  great.  Frequently  all  the 
children  in  a  family  will  be  attacked  upon  exposure.  One  attack  almost 


624  TEXT-BOOK  OF  PEDIATRICS 

always  confers  a  permanent  immunity.  Second  attacks  are  exceedingly 
rare.  The  fact  that  adults  are  so  rarely  affected  is  due  rather  to  acquired 
immunity  than  to  decreased  predisposition.  The  disease  is  generally  more 
common  in  the  cold  season  because  indoor  life  favors  transmission. 

The  contagious  quality  of  varicella  is  very  great.  Usually  conveyance 
is  direct  from  person  to  person.  Some  authors  doubt  that  indirect  trans- 
mission by  the  healthy  person  or  through  the  medium  of  utensils  can  occur. 
The  writer  is  quite  certain,  however,  that  he  has  seen  such  cases,  howsoever 
infrequent  they  may  be. 

The  virus  of  the  disease  is  very  light,  so  that  in  hospital  wards  transmis- 
sion seems  to  occur  along  the  lines  of  air  currents,  whence  has  been  begotten 
the  German  designation  of  "Windpocken"  and  the  French  term  "la  petite 
verole  volante."  The  mode  of  transmission  and  the  port  of  entry  are  still 
unknown.  The  contagion  is  most  active  at  the  beginning  of  the  exanthem. 
By  the  time  the  vesicles  appear  the  contagion  has  usually  taken  place; 
possibly  it  even  precedes  the  eruption.  How  long  the  period  of  contagion 
lasts  is  problematical,  but  doubtless  it  passes  by  the  time  the  vesicles  have 
dried  up.  The  viability  of  the  virus  outside  of  the  human  body  seems  to  be 
very  limited. 

In  Europe  the  disease  is  endemic.  There  are  small  or  large  epidemics, 
frequently  of  regional  distribution,  originating  in  playgrounds  or  schools. 

The  histologic  study  of  varicella  usually  shows  a  fan-like  structure,  the 
vesicle  being  situated,  as  in  small-pox,  between  the  epidermis  and  the  cor- 
ium.  The  differences  between  the  vesicles  of  varicella  and  those  of  variola 
are  merely  those  of  degree.  Morphologically  they  often  resemble  each 
other  in  every  particular. 

In  the  majority  of  cases  the  incubation  period  up  to  the  first  appearance 
of  the  rash,  covers  about  fourteen  days  and  is  probably  never  less  than 
thirteen.  Frequently  it  extends  to  seventeen  or  nineteen  days.  Such  an 
extension  of  the  incubation  period  is  occasionally  due  to  the  incidence  of 
intercurrent  infectious  disease. 

In  contrast  to  variola,  prodromal  symptoms,  are  entirely  lacking  in  the 
majority  of  cases,  or  are  so  slight,  that  they  are  apt  to  be  overlooked  in 
small  children.  Rarely,  a  slight  fever,  restlessness  and  disturbed  sleep  are 
noted  for  a  day  or  two  before  the  appearance  of  the  eruption.  Only  in  very 
exceptional  cases  does  the  temperature  rise  to  39°-40°C.  (102°-104°F.), 
with  the  accompaniments  of  vomiting,  intense  headache  and  backache. 
In  one  instance,  that  of  a  boy  of  four  years,  the  writer  has  witnessed  severe 
convulsions.  Sometimes  a  very  transient  rash,  very  similar  in  form  to  that 
of  a  slight  scarlatina  may  be  observed  for  twelve  to  twenty-four  hours  prior 
to  the  appearance  of  the  typical  eruption,  or  coincidently  with  it,  or  im- 
mediately following  it. 

Clinical  Picture. — Generally  the  disease  is  first  noticed  by  the  child's 
parents  when  the  exanthem  occurs.  The  eruption  usually  begins  on  the 
face  and  scalp,  speedily  developing  on  the  body  and  the  extremities.  At 
first  discrete  roseolar  spots  of  the  size  of  a  pinhead  appear.  Some  of  them 
enlarge  rapidly  to  the  size  of  a  lentil  and  a  part  of  them  become  slightly 


THE  ACUTE  INFECTIOUS  DISEASES  625 

raised  and  papular.  A  number  of  the  papules  show  a  tiny  vesicle  rising 
from  the  centre  within  a  few  hours.  This  vesicle  may  occupy  the  entire 
surface  of  the  papule  in  a  short  time.  The  edges  of  the  varcella  vesicle  are 
often  continuous  with  the  plane  of  the  normal  skin,  but  again  a  large  in- 
flamed base  appears  with  the  vesicle  standing  in  the  centre  of  the  raised  red 
papule  and  surrounded  by  a  red  ridge.  The  vesicles  are  of  the  average  size 
of  a  lentil  and  are  often  of  oval  or  hemispheric  form.  Sometimes  their  con- 
tent is  clear  and  at  other  times  slightly  cloudy  from  the  beginning.  A  shal- 
low depression  is  rarely  seen  at  the  apex  of  the  vesicle;  the  cloudiness 
increases  rapidly  and  the  contained  fluid  becomes  more  or  less  purulent.  In 
a  day  or  two  it  begins  to  dry  up  and  then  shows  a  distinct  depression  at  the 
apex.  Quite  frequently  the  vesicles  burst.  In  from  three  to  six  days  from 
their  first  appearance  they  have  dried  to  a  brown  crust.  With  the  disap- 
pearance of  the  red  inflammatory  areola,  which  is  often  entirely  lacking, 
a  characteristic  hard  brown  scab  is  formed  by  the  dried  pustule.  This  scab 
usually  falls  off  at  the  end  of  the  first  week,  but  may  remain  adherent 
through  the  second  or  third  week.  Commonly  it  leaves  no  scar. 

It  is  characteristic  of  the  disease  that  only  a  part  of  the  rash  becomes 
vesicular  or  pustulated,  the  remainder  of  the  spots  disappearing  after  they 
have  reached  the  roseolar  or  papular  stage.  In  the  majority  of  cases  new 
spots,  some  of  them  vesicular  appear  between  the  old  ones  for  a  period  of 
several  days  or  even  a  week,  so  that  all  stages  of  the  eruption  may  be  seen 
within  a  small  area. 

The  extent  of  the  eruption  is  extremely  variable.  Sometimes  only  four 
or  five  spots  can  be  found  over  the  entire  body,  again  in  other  cases  there 
may  be  many  hundreds.  On  the  face  they  may  be  as  dense  and  as  massed 
as  in  small-pox.  If  the  exanthem  becomes  markedly  purulent,  the  patient 
sometimes  gives  forth  a  peculiar  and  indescribable  odor.  As  it  dries  the 
eruption  of  varicella  often  causes  severe  itching,  especially  over  the  scalp. 
This  is  most  noticeable  in  neuropathic  patients  and  induces  scratching  and 
consequently  severe  infection  of  the  vesicles. 

The  mucous  membranes  and  particularly  the  mucosa  of  the  mou.th  are 
frequently  affected.  The  eruption  is  most  commonly  noted  on  the  soft 
palate  but  it  also  appears  on  the  tongue,  pharynx  and  cheeks.  Large  vesi- 
cles form  beneath  the  epithelium,  which  speedily  break  down  and  leave 
shallow  aphthous  sores,  which  heal  quickly.  The  suspicion  of  diphtheria, 
which  may  be  raised  at  first  sight  of  these  patches  is  quickly  allayed  upon 
careful  examination  even  in  cases  in  which  the  appearance  of  the  skin  erup- 
tion is  postponed — a  rare  occurrence.  In  some  instances  vesicles  form  in 
the  nose  and  are  accompanied  by  a  sanguine-purulent  secretion.  They  are 
also  found  occasionally  in  the  external  auditory  canal.  They  occur  much 
less  frequently  on  the  conjunctiva  than  in  the  mouth.  They  are  sometimes 
very  annoying  in  the  latter  location,  but  they  usually  heal  well.  It  is  fortu- 
nate, that  on  the  cornea  they  are  extremely  uncommon,  because  there  they 
may  cause  intense  inflammation  with  clouding  and  even  destruction. 

The  vulva  is  often  affected,  single  or  multiple  vesicles  appearing  which 
soon  become  macerated.     The  intense  itching  that  occurs  in  this  region 
40 


626  TEXT-BOOK  OF  PEDIATRICS 

makes  the  child  scratch  the  parts  and  as  a  result  a  secondary  purulent  infec- 
tion, phlegmon,  ulceration  and  in  severe  cases,  even  necrosis  develop.  The 
resulting  painful  urination  is  also  annoying.  This  affection  of  the  vulva  is 
especially  frequent  and  is  apt  to  be  intense  in  cases  in  which  a  vulvitis  has 
preexisted.  Eruptions  on  the  glans  penis  and  on  the  inner  surface  of  the 
prepuce  are  more  rare.  An  extremely  troublesome  but  fortunately  rare 
localization  of  the  vesicles  is  upon  the  vocal  cords.  So  situated,  they  are 
apt  to  cause  hoarseness,  croupy  cough,  and  even  stenosis,  with  attacks  of 
asphyxia  which  may  require  intubation.  Deaths  resulting  from  this  com- 
plication have  been  reported.  Occasionally  the  vesicles  on  the  vocal  cords 
appear  before  the  skin  eruption  and  the  symptoms  may  then  be  mistaken 
for  those  of  true  croup. 

The  temperature,  in  contrast  to  that  of  variola,  generally  rises  at  the 
onset  of  the  eruption.  If  fever  has  attended  the  prodromal  stage  the  tem- 
perature may  rise  to  39°  C.  (102°  F.)  or  more.  In  other  cases  the  tempera- 
ture is  merely  subfebrile  and  very  transient.  If  fever  is  present,  it  usually 
continues  as  long  as  new  crops  of  vesicles  appear  and  therefore  may  last  for 
a  week  or  two.  The  appearance  of  a  new  and  extensive  crop  often  causes 
renewed  accessions  of  temperature.  The  fever  may  remain  at  39°-40°  C. 
thus  (102°-104°  F.)  for  days,  while  the  disease  itself  is  not  necessarily  severe. 
Cases  are  also  reported  and  by  no  means  infrequently,  which  are  wholly 
free  from  fever.  This  conclusion  is,  however,  based  on  temperature  records 
taken  only  twice  a  day.  Other  cases  are  mildly  febrile  during  the  first  day 
of  the  eruption 

PECULIARITIES  OF  THE  EXANTHEM 

In  many  cases  the  effloresence  is  very  scanty.  Five  to  ten  vesicles  or 
but  a  single  one,  may  be  discoverable  over  the  entire  body.  In  such  cases 
the  diagnosis  is  of  course,  possible  only  in  the  light  of  concurrent  cases. 
The  difficulty  is  all  the  greater,  because  the  general  symptoms  are  usually 
slight  in  proportion  to  the  poverty  of  the  eruption.  In  other  instances  the 
crop  of  vesicles  may  be  extraordinarily  dense  and  in  some  areas  particularly 
over  the  face  or  forehead,  may  even  become  confluent.  In  severe  cases,  the 
skin  between  the  vesicles  is  reddened  and  swollen.  In  these  aggravated 
forms  of  eruption  the  individual  spots  are  often  noticeably  raised  and  even 
distinctly  papular  as  in  variola.  The  vesicles  become  markedly  purulent, 
the  inflammatory  areolse  broad  and  conspicuous.  The  entire  picture  may 
present  a  great  similarity  to  that  of  true  small-pox,  a  likeness,  which  is 
emphasized  when  high  fever  and  marked  disturbance  of  the  general  health 
ensue,  events  which  are  not  at  all  uncommon  with  an  intense  exanthem. 
Definitely  purulent  vesicles  leave  scars  which  may  be  permanent  following 
varicella.  Indeed  often  very  mild  cases  leave  a  few  scars,  especially  on  the 
surface  of  the  abdomen.  The  experienced  observer  is  often  able  years  later 
to  make  a  diagnosis  of  a  past  attack  of  chicken-pox  from  the  circular  form, 
the  pigmented  margin  and  the  localization,  preferably  on  the  trunk,  of  the 
numerous  remaining  scars. 

Too  warm  clothing  and  resulting  perspiration  often  aggravate  the  erup- 


THE  ACUTE  INFECTIOUS  DISEASES  627 

tion.  The  formation  of  vesicles  is  favored  by  the  use  of  heavy  bandages, 
moist  applications,  etc.,  or  by  the  employment  of  such  counterirritants  as 
the  mustard  plaster.  It  is  important,  therefore,  that  such  applications  be 
avoided,  since  an  increase  of  the  eruption  tends  to  make  the  disease  itself 
more  severe. 

The  vesicles  do  not  as  a  rule  exceed  the  size  of  a  lentil.  Occasionally, 
however,  a  very  large  vesicle  measuring  as  much  as  one  centimeter  in  diam- 
eter and  resembling  pemphigus  may  be  found  among  the  rest.  The  con- 
tent of  the  vesicles  rarely  becomes  hemorrhagic  and  this  probably  occurs 
only  in  children  who  have  a  hemorrhagic  diathesis  or  are  in  an  extremely 
cachectic  state.  The  exanthem  is  especially  prone  to  pus  formation  in  weak, 
tuberculous  infants  or  in  those  who  have  eczema.  Pus  formation,  the  pus- 
tules appearing  upon  a  markedly  raised  inflammatory  base  and  enlarging 
for  several  days,  is  favored  by  a  lack  of  cleanliness,  by  scratching  with  dirty 
finger-nails  or  by  maceration  of  the  skin  with  urine  or  feces.  In  such  cases, 
one  has  to  deal  with  a  secondary  infection  of  the  staphylococcus  or  strep- 
tococcus. The  pus  formation  doubtless  depends  also  upon  unknown  factors, 
since  even  perfectly  healthy  and  clean  children  may  show  a  peculiar  tend- 
ency to  severe  inflammatory  changes  around  the  vesicles  and  to  the  forma- 
tion of  scars,  while  in  others  the  transition  from  the  pustules  to  normal 
skin  is  direct. 

In  cachectic  individuals  the  pustules  sometimes  become  very  large  and 
lead  to  a  gangrene  of  the  skin.  Large,  punctiform  ulcers,  extending  into 
the  fascia  and  the  muscle  tissues  reaching,  at  times,  a  half-inch  in  diameter, 
may  be  formed.  It  is  not  surprising  that  these  should  lead  to  metastasis, 
general  sepsis,  and  death.  In  no  other  infectious  disease  is  gangrene  of  the 
skin  so  common  as  in  varicella.  This  termination  is  especially  to  be  dreaded 
in  exhausted  and  atrophic  children  in  hospitals,  to  which  varicella  may 
be  introduced. 

In  many  cases  of  the  disease  the  general  health  is  not  disturbed,  and  in 
most  of  them  in  fact,  is  not  essentially  affected.  Restlessness,  disturbed 
sleep,  diminished  appetite  and  itching  are  common  symptoms.  Headache, 
vomiting,  and  jactitation  appear  in  but  few  cases.  If  the  eruption  is  severe, 
high  fever  may  accompany  it.  In  adults  the  disease  usually  presents  more 
serious  symptoms  than  in  children.  With  them  the  exanthem  often  takes 
on  a  variola-like  character,  so  that  the  rare  cases  of  varicella,  that  appear 
among  adults  may  cause  the  physician  much  hesitancy  and  great  diagnostic 
difficulty.  This  is  especially  true  if  no  connection  with  other  cases  of  un- 
doubted varicella  can  be  traced. 

Complications  are  very  rare.  Besides  those  already  mentioned,  nephri- 
tis may  occasionally  appear  as  late  as  the  second  week  and  even  of  a  hemor- 
rhagic type.  Usually  it  disappears  in  a  short  time. 

The  course  of  the  disease  is  very  light  in  the  majority  of  cases.  The 
eruption  commonly  lasts  but  three  to  seven  days  and  children  may  be 
counted  well  by  that  time.  The  writer  has  seen  one  remarkable  case  in 
which  a  fresh  crop  of  the  exanthem  was  arrested  after  the  first  day  by  the 


628  TEXT-BOOK  OF  PEDIATRICS 

development  of  a  lobar  pneumonia.  The  crisis  appeared  on  the  eighth  day 
and  was  succeeded  by  an  intense  eruption. 

The  diagnosis  is  usually  easily  made.  The  discrete  exanthem  with  typi- 
cal vesicles,  later  indented  at  the  apex  and  subsequently  drying  up  is  to  be 
immediately  recognized.  Seen  even  later  the  dry  brown  scabs  on  the  clear 
skin  permit  a  definite  diagnosis  in  retrospect.  If  the  eruption  is  scanty, 
however,  the  diagnosis  may  be  very  difficult  and  may  be  definitely  made 
only  in  the  light  of  epidemiologic  conditions,  or  with  the  coincident  appear- 
ance, or  the  development  within  a  period  of  fourteen  days  of  other  cases  in 
the  family.  Frequently  distinct  vesicles  do  not  appear  or  are  so  scarce  that 
they  may  be  overlooked.  The  eruption  may  not  develop  beyond  the  ap- 
pearance of  a  faint  roseola  or  of  flat  papules.  One  or  two  small  vesicles 
perhaps  may  be  found  only  by  careful  search.  The  experienced  physician 
will  hardly  find  serious  difficulty  even  in  such  instances,  if  the  skin  was  nor- 
mal prior  to  the  eruption.  The  diagnosis,  however,  becomes  very  difficult 
if  the  eruption  occurs  on  a  skin,  which  had  been  previously  affected  with  a 
purulent  or  papular  eczema,  an  impetigo,  scabies,  etc.,  the  individual  ele- 
ments of  which  resemble  varicella.  In  such  cases  a  few  varicella  vesicles 
scattered  among  the  preexisting  lesions  may  be  readily  overlooked. 

The  differentiation  of  this  disease  from  variola1  is  of  great  importance. 
Usually  the  two  are  easily  distinguished.  In  small-pox  there  are  severe 
prodromes  and  the  temperature  falls  at  the  beginning  of  the  exanthem.  In 
varicella  distinct  prodromes  are  usually  wanting.  The  fever,  if  it  is  present 
at  all  usually  rises  at  the  beginning  of  the  eruption.  In  variola  the  eruption 
is  most  severe  on  the  face  and  palms  of  the  hands.  It  begins  on  the  face 
and  rapidly  spreads  to  the  neck,  body  and  extremities.  Distinct  papules 
with  marked  depressions  at  the  apex  and  with  extensive  pus  formation 
appear  in  the  latter  disease.  The  exanthem  of  variola  is  complete  within 
three  days,  so  that  it  is  in  the  same  stage  of  development  in  all  parts  of  the 
body  at  once.  On  the  other  hand  new  crops  of  vesicles  appearing  in  from 
three  to  seven  days  are  so  characteristic  of  varicella,  that  all  the  several 
stages  from  the  fresh  roseola  to  the  dried  pustule  may  be  seen  side  by  side. 
In  variola,  the  formation  of  the  vesicles  requires  several  days,  but  in  vari- 
cella, they  may  be  formed  within  a  few  hours.  In  this  latter,  secondary 
fever  due  to  pus  formation  is  generally  lacking.  Nevertheless,  all  these 
differences  are  very  slight  and  are  purely  qualitative.  This  is  especially 
true  in  those  mild  forms  of  small-pox  or  varioloid  seen  in  vaccinated  per- 
sons, which  may  be  very  similar  to  varicella.  Moreover,  it  is  to  be  con- 
stantly remembered  that  there  are  severe  cases  of  varicella,  which  cannot 
be  distinguished  from  variola  morphologically  and  in  which  there  may  be 
severe  prodromes  and  distinct  papules  and  pustular  formation.  On  the 
other  hand,  there  are  cases  of  variola,  which  run  a  mild  course  with  an  erup- 
tion scantier  than  in  varicella.  It  follows  that  the  most-  experienced  phy- 
sician may  be  unable  to  make  a  decision  for  several  days,  unless  aided  by 
the  concurrence  of  undoubted  cases  of  variola  on  the  one  hand,  or  by  a 

1  On  account  of  limited  space  a  detailed  description  of  small-pox  has  been  omitted. 


THE  ACUTE  INFECTIOUS  DISEASES  629 

definite  history  of  contagion  from  varicella  on  the  other.  It  is  well  to  con- 
sider all  doubtful  cases  as  variola  and  to  maintain  strict  isolation  until  the 
diagnosis  is  established.  Such  cases  should  not  be  isolated  with  small-pox, 
however,  without  previous  vaccination.  At  present  there  is  no  way  in 
which  the  efflorescence  of  varicella  and  variola  can  be  distinguished,  since 
the  pathologic  anatomy  of  the  two  conditions  is  identical.  From  the  variola 
pustule  the  disease  may  be  transmitted  by  vaccination  to  a  healthy  person, 
while  this  is  impossible  from  the  varicella  vesicle.  This  test,  however,  can 
hardly  be  applied.  In  a  general  way  a  suspicious  exanthem  in  an  unvac- 
cinated  person  or  in  one  who  has  not  been  vaccinated  for  over  seven  years, 
especially  if  it  be  in  the  adult  is  rather  indicative  of  variola.  This  is  partic- 
ularly true  if  the  eruption  is  scanty  and  becomes  distinctly  papular  and 
pustular.  Animal  experiments  may  be  used  as  an  aid  to  differential  diag- 
nosis. If  the  cornea  of  a  rabbit  be  vaccinated  with  the  contents  of  a  small- 
pox vesicle,  certain  inclusions,  known  as  Guarnier's  bodies,  are  found  in  the 
cells  of  the  cornea  on  the  second  day.  These  bodies  may  also  be  obtained  by 
the  use  of  vaccine  pustules  but  not  by  the  contents  of  the  varicella  vesicles. 

While  we  must  appreciate  the  weight  of  the  argument  of  those,  who 
believe  that  variola  and  varicella  are  one  and  the  same  disease  and  that  the 
clinical  picture  and  the  morphology  of  the  exanthem  show  no  differences 
in  individual  cases,  there  can  be  no  doubt  to-day  that  the  two  are  separate 
and  distinct  diseases.  The  single  fact,  that  varicella  is  just  as  common  in 
countries  where  vaccination  is  compulsory  as  in  those  where  vaccination 
is  not  enforced,  is  sufficient  proof.  Either  vaccination  or  one  attack  of 
variola  doubtless  protects  against  this  disease  but  not  against  varicella. 
Unvaccinated  persons  are  affected  by  variola,  in  spite  of  the  fact  that  they 
may  have  had  varicella.  In  unvaccinated  persons,  who  have  had  chicken- 
pox,  vaccination  takes,  but  this  is  exceptional  in  those  who  have  had  small- 
pox. During  epidemics  it  has  often  happened  that  a  child  placed  in  the 
small-pox  hospital  on  a  mistaken  diagnosis  has  often  caused  an  outbreak 
of  varicella  there  and  vice  versa  a  case  supposed  to  be  chicken-pox  may 
have  created  a  small-pox  epidemic  in  the  varicella  ward.  The  difficulty  of 
differentiation  has  often  occasioned  the  conscientious  physician  great  anx- 
iety and  he  does  well  to  share  the  responsibility  with  an  epidemiologist. 
The  danger  of  confusion  is  especially  great  in  Germany  where  small-pox  is 
so  uncommon,  so  that  a  case  may  not  be  recognized  when  it  does  appear. 
It  may  be  that  the  hyper-lymphocytosis  which  often  occurs  in  variola  will 
have  a  diagnostic  value. 

The  difficulties  of  the  differentiation  of  varicella  from  other  diseases  are 
not  so  great.  Occasionally  a  large  pemphigus-like  character  of  the  vesicles 
result  from  their  continued  enlargement,  but  typical  varicella  vesicles  may 
usually  be  found  near  by  or  repeated,  new  crops,  appearing  for  weeks  may 
show  that  the  disease  is  really  pemphigus.  Secondary  lues  in  exceptional 
cases  may  show  an  exanthem  similar  to  varicella.  The  writer  has  seen  a 
case  in  an  adult  in  whom  the  distinction  could  not  be  made  from  the  mor- 
phologic appearance  during  the  first  few  days.  Not  infrequently  forms  of 
strophulus  are  seen  in  lymphatic  children  in  which  the  usual  papule  becomes 


630  TEXT-BOOK  OF  PEDIATRICS 

vesicular  with  or  without  a  basal  urticaria,  a  prurigo  varicelliformis.  The 
firmness  and  often  the  glassy  hardness  of  the  vesicle  is  a  definite  criterion 
of  distinction. 

The  prognosis  is  good  in  the  large  majority  of  cases.  The  disease  is 
severe,  or  even  fatal  in  very  exceptional  cases  only  and  this  severity  is 
usually  shown  in  feeble,  cachectic  patients.  In  healthy  children  varicella 
is  very  rarely  fatal.  Nevertheless,  the  author  has  seen  a  strong  infant  of 
three  months  with  a  hardly  noticeable  rash  die  of  sepsis  at  the  end  of  the 
first  week.  In  children  suffering  with  purulent  eczema  the  course  of  the 
disease  is  generally  less  favorable,  since  the  exanthem  usually  becomes  mark- 
edly infected.  Frequently  it  has  been  observed  that  a  latent  or  an  insignif- 
icant exudative  diathesis  or  an  incipient  tuberculosis  becomes  active  after 
recovery  from  varicella. 

Prophylaxis  must  not  be  neglected  in  view  of  the  possible  danger  of  a 
serious  course  or  a  fatal  termination.  Infants  and  feeble  children  should 
be  isolated  whenever  it  is  possible  as  soon  as  a  case  appears  in  the  family. 
In  children's  hospitals  the  danger  of  a  case  being  brought  in  is  especially  to 
be  dreaded.  If,  however,  this  has  occurred  and  it  cannot  always  be  avoided 
on  account  of  the  long  incubation  period,  the  continuance  of  the  disease  in 
the  ward  can  be  limited  only  by  forbidding  new  admissions  for  three  weeks 
and  then  disinfecting  the  room.  If  there  is  a  suspicion  that  the  case  may 
be  one  of  small-pox,  it  must  be  carefully  isolated  and  all  the  children  in  the 
house  vaccinated,  since  vaccination  protects  against  small-pox  even  a  day 
or  two  after  exposure. 

The  treatment  of  mild  cases  is  expectant.  So  long  as  there  is  fever  and 
as  fresh  crops  of  the  eruption  appear,  the  patients  should  be  kept  in  bed 
and  on  a  light  liquid  diet.  The  severe  itching  may  be  relieved  by  a  1  per 
cent,  mixture  of  salicylic  acid  with  talcum  powder,  by  painting  with  men- 
tholated alcohol  (]/2  per  cent.),  or  with  a  1  percent,  thymol  ointment.  The 
finger-nails  should  be  cut  short.  Baths,  packs  and  other  procedures  tend- 
ing to  increase  the  eruption  must  be  avoided.  If  the  mouth  is  involved,  it 
should  be  rinsed  and  the  throat  gargled  with  some  bland  solution  such  as 
boric  acid  or  2  per  cent,  hydrogen  peroxide.  A  painful  ulcer  in  the  mouth 
may  be  touched  with  a  2  per  cent,  solution  of  silver  nitrate.  The  eruption 
affecting  the  vulva,  must  be  kept  scrupulously  clean  and  should  be  pro- 
tected from  maceration  by  the  use  of  powder  or  ointment  and  strips  of 
gauze.  Large  pustules  containing  much  pus  may  be  covered  with  a  drying 
paste  and  ulcerous  or  gangrenous  areas  must  be  bandaged. 

VACCINATION  (COW-POX) 

In  India,  it  was  observed  in  ancient  times  that  one  attack  of  small-pox 
conferred  very  definite  protection  against  a  second  attack  and  various 
methods  of  vaccination  with  old  small-pox  virus  were  practiced.  In  the 
eighteenth  century  many  persons  were  inoculated  in  Europe,  after  Lady 
Montague  had  introduced  the  practice  to  the  western  world  from  Constan- 
tinople. But  inoculation  was  later  discontinued  and  even  prohibited  in 
many  countries  since  people  not  infrequently  died  from  an  induced  small- 


THE  ACUTE  INFECTIOUS  DISEASES  631 

pox.    Another  unfortunate  circumstance  was  that  real  epidemics  repeatedly 
arose  from  this  practice. 

The  present  method  of  vaccination  dates  from  the  famous  English 
physician,  Jenner,  who  first  practiced  it  in  1796  and  who  received  for  his 
discovery  many  rewards  from  the  English  Parliament.  Observing,  that  a 
certain  udder  disease  of  cows  popularly  termed  cow-pox,  occasionally 
infected  the  hands  of  milkers  and  that  those  who  were  so  affected  later 
escaped  small-pox,  he  conceived  the  idea  of  inoculating  persons  with  the 
content  of  the  vesicles  developed  in  the  disease  in  the  cow  in  order  to  protect 
them  from  future  attacks  of  small-pox.  The  results  justified  his  surmise. 
Persons  so  vaccinated  proved  to  be  insusceptible  to  intentional  inocu- 
lation with  small-pox  virus.  Jenner's  theory,  that  this  vaccine  is  nothing 
more  than  an  attenuated  variola  on  the  body  of  the  cow  has,  however,  been 
proved  to  be  correct  but  recently  by  Voigt  and  others.  With  the  passage 
of  the  disease  through  the  animal  it  loses  its  power  to  spread  through  the 
air  and  to  cause  a  general  skin  eruption. 

At  the  beginning  of  the  last  century  Jenner's  method  of  protective  vac- 
cination was  introduced  into  many  European  states  with  remarkable 
results.  It  soon  appeared,  however,  that  the  protection  which  it  conferred 
did  not  persist  as  long  as  that  resulting  from  the  disease  itself  and  that 
vaccinated  persons  again  become  increasingly  susceptible  to  small-pox  with 
the  lapse  of  years.  During  epidemics  it  has  been  found,  that  children  vac- 
cinated, early  again  become  more  and  more  liable  to  the  disease  after  the 
seventh  year  and  are  affected,  in  fact,  in  increasing  numbers.  In  such  cases, 
however,  the  malady  usually  appears  in  an  attenuated  form  known  as  vario- 
loid.  In  older  people  the  protection  secured  by  vaccination  commonly  per- 
sists for  a  longer  time. 

The  vaccination  law  in  Germany  in  effect  since  1874,  requires  that 
every  healthy  child  shall  be  vaccinated  by  the  end  of  the  calendar  year 
following  its  birth  and  that  the  vaccination  must  be  repeated  in  the  twelfth 
year.  This  law  fulfills  a  practical  requirement  and  as  a  result  but  very  few 
cases  of  small-pox  have  been  seen  in  that  country  since  that  time.  These 
few  are  usually  brought  in  from  some  foreign  country  and  can  never  cause 
a  widespread  epidemic. 

In  countries  in  which  vaccination  is  not  compulsory  or  in  which  vaccina- 
tion laws  are  indifferently  enforced,  we  still  see  large  epidemics  of  variola, 
which  can  be  stopped  only  under  good  hygienic  conditions  and  strict  isola- 
tion of  the  sick.  Nevertheless  since  the  days  of  Jenner,  the  antivaccina- 
tionists  have  never  ceased  their  agitation  and  renew  their  protests  and 
petitions  against  compulsory  vaccination  from  year  to  year.  They  raise 
the  plea  that  vaccination  does  not  protect  against  small-pox.  How  pre- 
posterous is  the  claim  is  shown  by  the  comparison  of  the  experience  of 
modern  times  in  those  countries  where  there  is  compulsory  vaccination 
with  the  history  of  these  countries  before  Jenner's  discovery,  when  small-pox 
was  the  most  serious  disease  known.  It  is  further  proved  by  the  epidemics 
which  have  frequently  occurred  in  countries  after  compulsory  vaccination 
had  been  abandoned  as  in  England  and  in  several  of  the  Swiss  cantons. 


632  TEXT-BOOK  OF  PEDIATRICS 

The  objection  has  been  brought  forward,  that  syphilis  and  tuberculosis  are 
transmissible  by  vaccination.  Formerly,  when  it  was  the  custom  to  vac- 
cinate from  persons  to  person  with  humanized  lymph,  lues  was  actually 
transmitted  quite  frequently  as  a  result  of  the  careless  selection  of  persons 
giving  the  vaccine.  No  case  in  which  tuberculosis  was  so  transmitted  has 
ever  been  proved.  Since  calves'  lymph  has  been  solely  employed,  the 
animals  being  slaughtered  and  examined  before  the  vaccine  is  used,  the 
transmission  of  syphilis  has  become  impossible.  The  statement  of  the  anti- 
vaccinationists,  that  the  health  of  children  may  be  injured  for  life  is  to 
be  discussed. 

The  best  time  to  vaccinate  children  is  between  the  fifth  and  the  twelfth 
months.  Infants  fed  at  the  breast  may  be  vaccinated  during  the  first  week. 
Artificially-fed  children  should  not  be  vaccinated  during  the  hot  months  of 
the  year  unless  there  is  immediate  danger  of  small-pox.  If  a  case  of  small- 
pox occurs  in  a  family,  a  member  of  which  has  not  been  vaccinated,  imme- 
diate vaccination  may  still  be  protective  against  the  disease,  since  immunity 
is  fully  established  in  eight  days.  The  lymph  to  be  used  must  be  obtained 
from  a  licensed  institution  and  should  not  be  older  than  three  months.  The 
technic  is  extremely  simple,  but  it  requires  the  same  asepsis  as  any  other 
surgical  procedure.  The  child  is  bathed  on  the  preceding  day,  and  prior 
to  vaccination  the  selected  area  of  operation  is  to  be  cleansed  with  ether. 
The  outer  side  of  the  right  arm  is  usually  chosen  or,  in  event  of  revaccina- 
tion  the  left  arm.  Four  shallow  scratches  about  one  centimeter  long  and 
crossing  each  other  two  by  two  are  made.  The  entire  area  covered  should 
be  about  three  square  centimeters.  A  vaccination  lance  or  a  large  surgical 
needle  thoroughly  sterilized  is  used.  A  drop  of  lymph  is  previously  placed 
upon  the  instrument  from  the  capillary  tube,  so  that  it  will  run  into  the 
scratches.  These  scratches  should  be  so  slight,  that  they  produce  only  a 
faint  red  line.  There  must  be  no  free  blood.  The  vaccine  virus  does  not 
need  to  be  rubbed  in.  The  wound  is  allowed  to  dry  for  ten  minutes.  Dur- 
ing this  time  the  child  must  be  so  held,  so  that  it  cannot  touch  the  vacci- 
nated area  and  that  the  clothing  does  not  rub  over  it.  After  the  drying  is 
completed  it  is  well  to  cover  the  area  thoroughly  with  collodion.  This  pro- 
cedure the  writer  has  found  extremely  useful  and  when  employing  it,  he  has 
never  had  a  vaccine  infection  in  other  parts  of  the  body  or  in  other  members 
of  the  family.  Usually,  a  light  cotton  bandage  is  placed  over  the  area,  which 
may  remain  in  place  for  several  days  and  serves  to  protect  the  vaccination 
from  scratching.  If  a  little  of  the  cotton  adheres  to  the  wound,  this  is  not 
to  be  disturbed.  If  it  is  necessary  to  change  the  bandage  it  may  be  trimmed 
away  from  the  area  with  the  scissors.  Vaccination  shields  are  unnecessary 
and  may  even  prove  harmful,  if  they  prevent  the  drying  of  the  vaccinated 
spot.  In  girls  the  vaccination  may  be  done  upon  the  outer  surface  of  the 
thigh,  if  the  avoidance  of  a  scar  upon  the  arm  is  desired.  The  chest  imme- 
diately below  the  breast  may  be  preferred. 

The  child  may  be  bathed  the  day  after  the  vaccination,  but  after  that 
tub  baths  should  be  discontinued  until  the  scab  has  dried  up,  which  will  be 
about  the  fourteenth  day. 


THE  ACUTE  INFECTIOUS  DISEASES  633 

After  the  first  vaccination  the  inoculated  area  immediately  shows  a 
slight  reddening  as  the  direct  result  of  the  trauma.  This  disappears  hi  a 
day  or  so.  Then  a  thin  brownish  line  marks  the  scarified  spot.  Within 
two  or  three  days  the  brown  line  is  edged  with  a  red  border  which  soon 
changes  to  a  reddish  ridge  or  vaccination  papule.  This  papule  becomes 
more  and  more  prominent  and  wider  from  day  to  day.  After  the  fifth  or 
sixth  day  it  grows  pale  at  the  centre  and  a  flat  areola  rising  prominently 
from  the  surrounding  red  skin,  is  formed.  The  whitish  papule  enlarges 
continually  until  the  ninth  day,  but  after  the  seventh  day  it  becomes  yel- 
lowish. Its  centre  becomes  depressed  over  the  point  of  the  original  scratch. 
The  papule  itself  is  now  vesicular  and  when  squeezed  discharges  a  clear 
lymph,  the  humanized  lymph,  which  was  formerly  used  for  further  vaccina- 
tions. The  red  areola  now  becomes  still  wider  and  rises  as  a  plateau  above 
the  surrounding  unchanged  skin.  Its  area  varies  in  size.  Frequently  the 
sites  of  the  four  separate  scratches  become  confluent  and  form  an  erysipe- 
loid  area.  This  may  attain  to  a  diameter  of  three  or  four  inches.  The  reac- 
tion reaches  its  height  in  nine  or  ten  days,  after  which  the  papule  begins  to 
dry  up  rapidly  from  the  centre  outward.  Meanwhile  the  papule  has  been 
growing  more  and  more  yellowish  and  when  it  begins  to  dry  up  it  changes 
into  a  hard  brownish  scab.  This  falls  off  in  from  two  and  a  half  to  four 
weeks  and  leaves  a  red  scar,  which  pales  very  slowly.  With  the  further 
drying  of  the  papule  the  red  wall  surrounding  it  fades  rapidly,  but  becomes 
pigmented  at  the  edge.  It  will  usually  have  disappeared  completely  some 
twelve  or  fourteen  days  after  the  vaccination.  According  to  von  Pirquet 
the  organism  forms  two  distinct  antibodies  against  the  vaccine  virus;  the 
first,  a  lysine,  which  liberates  a  toxin  from  the  virus  around  the  point  of 
inoculation,  causing  the  formation  of  the  areola,  the  vaccination  process 
being  terminated  by  the  formation  of  a  toxic  antibody. 

Intercurrent  acute  diseases,  such  as  scarlet  fever,  measles,  etc.,  may 
delay  the  development  of  the  vaccine  reaction  for  a  short  time. 

The  general  health  usually  shows  no  disturbance  during  the  first  few 
days  after  vaccination.  After  the  fifth  or  sixth  day,  a  slight  febrile  rise 
may  set  in,  which  even  under  ordinary  conditions  may  go  to  39°  C.  (102°  F.). 
Accordingly  the  vaccinated  child  is  often  less  active  than  usual  between 
the  seventh  and  the  tenth  or  eleventh  days.  Sleep  may  be  disturbed  and 
the  appetite  diminished  while  the  vaccination  remains  painful.  The  regional 
lymph  nodes  are  slightly  and  occasionally  markedly  swollen  so  that  the 
child  may  complain  of  pain  if  lifted  beneath  the  arm. 

A  subsequent  examination,  which  should  ordinarily  be  made  on  the 
seventh  or  eighth  day,  shows  a  large  white  papule  with  a  slightly  developed 
inflammatory  areola  around  it.  The  reaction  does  not  reach  its  maximum 
until  the  ninth  or  tenth  day.  After  the  seventh  day  a  little  of  the  vesicular 
contents  may  occasionally  escape.  The  parents  should  be  warned  against 
the  customary  procedure  of  applying  some  favorite  salve,  since  this  will 
delay  the  normal  retrograde  changes  and  prevent  the  vesicle  from  diying 
up  and  may  invite  pus  formation. 

Revaccination  is  essentially  different  in  its  course.    It  has  been  exhaust- 


634  TEXT-BOOK  OF  PEDIATRICS 

ively  studied  by  von  Pirquet  who  derived  the  conception  of  his  well-known 
cutaneous  tuberculin  reaction  from  these  studies.  One  vaccination  per- 
manently changes  the  power  of  the  organism  to  react  to  future  vaccinations 
or  to  infection  with  variola. 

If  the  second  vaccination  takes  place  a  few  months  after  a  positive  reac- 
tion has  occurred,  a  very  small  papule  appears  in  a  very  few  days  and  disap- 
pears as  rapidly.  In  this  event  the  disease  has  been  nipped  in  the  bud.  A 
few  years  after  the  first  vaccination  the  susceptibility  to  vaccinia  is  usually 
found  to  have  increased  again.  Hence  the  formation  of  a  papule  and  areola 
will  occur  as  in  the  first  vaccination  but  the  reaction  is  less  intense.  The 
papule  remains  small  and  the  entire  process  reaches  its  maximum  height 
by  the  seventh  day.  As  a  result  the  scar  formation  is  also  slight.  In  the 
adult  the  reddening  is  at  times  very  widespread  and  may  even  extend  to 
the  forearm.  The  swelling  of  the  lymph  nodes  is  severe  and  painful. 

PECULIARITIES  OF  COURSE  AND  COMPLICATIONS 

In  general  it  may  be  said  that  the  younger  the  child — when  vaccinated, 
the  milder  is  the  reaction.  Children  who  are  vaccinated  for  the  first  time 
after  some  years  and  those  who  are  unvaccinated  until  adult  life  usually 
react  intensely  with  the  formation  of  a  large  pustule,  a  widespread  erysipel- 
atous  areola,  a  marked  fever  and  with  serious  disturbance  to  the  general 
health.  Edema  may  appear  on  the  arm. 

In  anemic  and  cachectic  children  the  reaction  is  usually  peculiar  in  that 
the  areola  is  slow  of  formation  and  poorly  developed,  giving  the  papule  the 
opportunity  to  spread.  The  severity  of  the  reaction  is  also  determined  by 
the  virulence  of  the  vaccine  and  by  the  quantity  inoculated.  With  a  viru- 
lent vaccine  small  eruptions  of  the  size  of  a  pinhead,  often  develop  in  the 
areola  from  the  fifth  to  the  seventh  day,  which  go  through  all  the  same  retro- 
grade changes  as  do  the  eruptions  of  small-pox  on  the  skin  at  large.  These 
accessory  or  secondary  pox  were  a  very  common  manifestation,  when  vac- 
cination was  formerly  done  with  true  small-pox  virus.  With  weak  or  di- 
luted vaccine  the  reaction  may  be  retarded  and  may  not  reach  its  maximum 
intensity  for  eleven  or  twelve  days.  The  reaction  occurs  more  rapidly  in 
summer  than  in  winter.  High  fever  is  common  with  strong  children  and  is 
no  cause  for  anxiety,  if  it  disappears  within  the  second  week.  If  this  subsid- 
ence is  not  noted,  some  complication  is  to  be  suspected. 

A  vaccine  exanthem  occasionally  appears  during  the  decline  of  the  reac- 
tion. It  usually  develops  between  the  eighth  and  twelfth  days,  but  it  may 
be  of  either  earlier  or  later  occurrence.  It  is  generally  similar  in  form  to 
that  of  measles  and  is  seen  on  the  face,  the  trunk  and  the  extensor  surfaces 
of  the  extremities.  At  times  it  resembles  scarlatina  or  a  miliary  pemphigus. 

This  exanthem  may  be  understood  when  it  is  remembered  that  a  rash 
always  appeared  at  about  the  same  time  in  persons  inoculated  with  small- 
pox. This  rash  was  usually  varioloid  in  form.  Since  the  virus  of  variola  is 
attenuated  by  repeated  passage  through  animals,  the  exanthemata  which 
may  develop,  when  vaccine  produced  in  the  usual  manner  is  used,  are  also 
slight  and  are  ordinarily  absent. 


THE  ACUTE  INFECTIOUS  DISEASES  635 

Albuminuria  may  appear  for  a  short  time  but  has  no  particular  significance. 

The  result  of  vaccination  may  be  considered  positive  when  at  least  one 
focus  of  inoculation  develops  a  normal  pustule.  This  usually  satisfies  the 
requirements  of  the  vaccination  laws.  Its  acceptance  is  justified  by  the 
fact  that  a  second  vaccination  produces  no  further  reaction  and  the  failure 
of  a  non-vaccinated  child  to  react  to  vaccine  is  an  extremely  rare  occur- 
rence. If  the  first  vaccination  causes  no  reaction  at  all,  it  should  be  repeated 
within  eight  days.  Then  it  frequently  happens  that  the  still  latent  virus  of 
the  first  vaccination  increases  the  reaction.  Such  latency  accounts  for  the 
fact  that  a  reaction  may  at  times  be  delayed  for  weeks.  This  peculiar  cir- 
cumstance is  probably  due  to  the  fact,  that  the  virus  does  not  properly 
penetrate  the  skin  and  is  finally  brought  in  touch  with  an  efficient  soil 
through  the  friction  of  the  clothing,  etc. 

Injuries,  actually  attributable  to  the  vaccination  may  be  avoided  by  a 
careful  technic  and  by  due  selection  of  the  individuals  to  be  vaccinated. 
Secondary  infection  of  the  pustule  with  pyogenic  organisms  hardly  ever 
occurs  if  the  wound  is  properly  treated  and  more  particularly  if  the  patient 
is  not  allowed  to  scratch  the  pustule.  If  such  an  infection  does  develop,  it 
heals  rapidly  under  suitable  treatment.  A  late  erysipelas  may  find  an 
opportunity  of  development  in  the  infected  pustule.  The  condition  gener- 
ally regarded  as  a  vaccine  erysipelas  is  really  a  part  of  the  vaccination  proc- 
ess and  means  merely  an  unusually  large  areola,  which  carries  with  it  no 
unfortunate  results.  A  diagnosis  of  true  erysipelas  is  only  to  be  made,  if  the 
disease  is  ushered  in  by  fever  arising  after  the  disappearance  of  the  areola. 
Extensive  pus  formation  in  the  pustule  and  attending  suppuration  of  the 
regional  lymph  nodes  are  not  to  be  expected  in  healthy  children,  whose  vac- 
cination wound  has  been  kept  dry.  Such  conditions  will  heal  rapidly  if 
they  are  treated  with  applications  of  an  aluminium  acetate  solution  or  with 
an  iodoform  dressing.  While  general  sepsis  might  arise  from  a  vaccination 
as  from  any  other  wound,  yet  scrupulous  asepsis  both  during  the  operation 
and  during  the  reaction  is  an  absolute  protection. 

Considering  the  enormous  number  of  infants  vaccinated  in  countries, 
in  which  vaccination  is  compulsory  it  is  not  surprising,  that  disease  is  often 
concurrent,  a  purely  accidental  coincidence  and  without  any  causal  relation. 
Such  cases  are  of  course,  immediately  seized  upon  by  the  antivaccination- 
ists  and  even  by  parents  and  are  counted  due  to  the  inoculation.  For  this 
very  reason  physicians  should  be  all  the  more  scrupulous  in  seeing  to  it  that 
no  injury  is  done  that  can  be  charged  either  to  him  or  to  the  event.  In  very 
anemic  or  cachectic  children  or  in  those  who  are  sick,  vaccination  should 
be  postponed.  In  children  of  exudative  diathesis,  an  eczematous  eruption 
following  vaccination  is  frequently  observed  (Czerny)  and  in  the  tubercu- 
lous the  appearance  of  scrofulous  manifestations  may  be  excited.  Luetic, 
atrophic  or  seriously  rickitic  children  should  not  be  vaccinated,  since  the 
vesicles  tend  to  ulcerate  in  such  patients  (Klotz). 

A  great  danger  attending  vaccination  lies  in  the  danger  of  spreadingfrom 
the  inoculation  site,  resulting  in  the  formation  of  pustules  in  other  parts  of  the 
body.  Such  an  extension  is  always  possible,  but  it  is  a  very  rare  occurrence, 


636  TEXT-BOOK  OF  PEDIATRICS 

if  the  vaccination  point  itself  receives  proper  attention.  The  most  unpleas- 
ant consequences  almost  always  follow  in  infants,  who  are  suffering  with 
eczema.  If  but  a  trace  of  fresh  vaccine  is  carried  to  the  eczematous  surface 
by  the  infant  itself  or  by  the  nurse  a  severe  and  widespread  eruption  of 
vaccinia  may  result.  The  face  is  most  frequently  involved.  The  condition 
may  be  accompanied  by  serious  illness  and  permanent  and  disfiguring  scars 
may  remain.  Governed  by  the  period  of  transmission  umbilicated  pustules, 
vesicles,  or  mere  papules  appear.  It  follows  that  children  with  eczema  or 


FIG.  163. — Eczema  vaccinatum,  eighteen-month-old  child. 
Infected  from  the  vaccination  pustule  of  a  vaccinated  sister. 
Sixth  day  of  the  disease. 

with  any  other  irritative  skin  lesion  should  be  vaccinated  only  under  very 
exceptional  circumstances  and  then  the  area  of  vaccination  should  be  cov- 
ered with  collodion  and  bandaged,  while  the  eczema,  also,  should  be  care- 
fully protected. 

A  spontaneous  general  vaccinia  probably  spreads  by  way  of  the  blood. 
In  such  a  case  the  entire  efflorescence  will  show  a  uniform  stage  of 
development. 

Another  and  even  greater  danger  ensuing  upon  vaccination  is  often 
overlooked  and  this  lies  in  the  possibility  of  the  accidental  inoculation  of 
unvaccinated  persons,  who  come  in  contact  with  the  vaccinated  child. 
Such  an  inoculation  may  be  due  to  the  introduction  either  of  the  fresh  vac- 


THE  ACUTE  INFECTIOUS  DISEASES  637 

cine  or  of  the  content  of  the  pustules.  As  a  result  of  such  contact  with  the 
vaccination  of  the  child,  a  pustule  may  form  in  some  such  critical  spot  as 
the  eye  of  the  mother  or  the  nurse  who  may  be  unvaccinated  or  in  whom 
vaccination  may  be  of  remote  date.  Unvaccinated  children  living  in  close 
contact  with  the  recently  vaccinated  child,  and  especially  those  who  have 
such  skin  affections  as  eczema  stand  in  special  danger.  A  widespread  and 
severe  vaccinia  may  arise  as  we  have  seen,  from  the  inoculation  of  the  dis- 
eased skin.  This  occurs  more  readily  with  the  contents  of  the  mature  pus- 
tule, the  virulence  of  which  lasts  until  about  the  eleventh  day,  than  it  does 
with  the  fresh"  vaccine.  The  accompanying  picture  (Fig.  163)  is  that  of  an 
unvaccinated  two-year-old  child  having  a  slight  eczema  on  the  arm  and 
face,  which  was  inoculated  with  the  content  of  the  pustule  of  a  successful!}' 
vaccinated  brother.  This  eczema  vaccination  resembles  a  severe  variola 
very  closely.  The  child  died  of  a  complicating  purulent  meningitis. 

In  view  of  these  dangers  children,  who  have  unvaccinated  brothers  or 
sisters,  who  are  suffering  with  eczema  should  not  be  vaccinated,  unless 
positive  assurance  can  be  given,  that  all  necessary  protective  measures 
will  be  scrupulously  carried  out.  It  is  the  physician's  duty  to  protect  per- 
sons closely  associated  with  the  vaccinated  child  from  accidental  inocula- 
tion. This  is  most  satisfactorily  accomplished  by  covering  the  vaccinated 
area  with  collodion  and  a  bandage  and  by  preventing  the  scratching  of  the 
vaccination  papule.  Von  Pirquet  recommends  the  careful  washing  of  the 
vaccinated  area  after  twelve  hours  instead  of  covering  with  collodion. 
We  have  carefully  tried  out  the  collodion  method  and  other  physicians  also 
recommend  it. 

The  severe  injuries  described,  resulting  from  vaccination  are,  of  course 
extremely  uncommon.  If  they  seem  to  be  given  greater  emphasis  than 
their  frequency  appears  to  justify,  it  is  simply  because  with  their  very  infre- 
quency  they  are  often  unrecognized  and  because  vaccination  is  a  procedure, 
which  must  be  enforced  with  healthy  children.  Furthermore,  the  report  of 
every  injury  resulting  from  vaccination  is  seized  by  the  antivaccination- 
ists  as  a  weapon  to  be  used  in  their  combat  against  this  wonderful  agent 
of  prevention. 

DIPHTHERIA 

Diphtheria  is  a  contagious  disease,  caused  by  Loeffler's  diphtheria  bacil- 
lus, the  most  important  symptom  of  which  is  a  membranous  exudation 
upon  certain  mucous  membranes,  especially  those  of  the  pharynx  and  the 
upper  respiratory  passages,  a  disease  which  produces  peculiar  toxic  effects 
and  resulting  sequelae  in  the  way  of  paralyses,  etc. 

Diphtheria  has  probably  been  known  for  a  long  period:  It  is  certain 
that  it  appeared  in- frightful  epidemics  in  Spain  during  the  sixteenth  and 
seventeenth  centuries.  The  first  classical  description  of  the  disease  is  writ- 
ten by  the  eminent  French  physician,  Bretonneau,  who  gave  it  the  name 
Diphtheria  (1826).  Up  to  the  middle  of  the  nineteenth  century  the  disease 
appeared  in  Germany  chiefly  as  a  primary  affection  of  the  larynx  and  bronchi, 
to  which  the  name  of  membranous  croup  and  membranous  bronchitis  were 


638  TEXT-BOOK  OF  PEDIATRICS 

given.  The  affection  of  the  pharynx  became  more  common  in  1860,  when 
numerous  German  physicians  saw  it  for  the  first  time. 

The  causative  organism  was  shown  by  Loeffler,  in  1884,  to  be  the  diph- 
theria bacillus.  He  succeeded  also  in  producing  a  membrane  in  rabbits  by 
the  inoculation  of  lesions  in  the  trachea.  The  Loeffler  bacillus  was  generally 
acknowledged  to  be  the  infective  organism  when  Roux  and  Yersin  succeeded 
in  producing  the  same  paralysis  in  animals  as  diphtheria  causes  in  man. 

The  diphtheria  bacillus  belongs  to  the  group  of  coryne  bacteria  and 
shows  great  variation  in  form,  growth  and  virulence.  It  is  usually  a  straight 
or  slightly  curved,  or  club-shaped  rod,  about  as  long  as  the  tubercle  bacillus 
but  much  thicker.  It  stains  readily  especially  with  Loeffler's  methylene 
blue.  On  account  of  its  irregular  staining  quality  it  often  appears  granular. 
Besides  the  very  short  young  forms,  long  club-shaped,  degenerative  forms 
are  also  seen. 

The  bacillus  grows  very  well  on  Loeffler's  blood  serum  and  moist  smoke 
colored  colonies  may  be  recognized  in  from  sixteen  to  twenty-four  hours. 
The  organism  is  not  affected  by  cold  but  is  rapidly  destroyed  at  a  tempera- 
ture of  56°  C.  (133°  F.).  It  is  also  very  sensitive  to  the  stronger  antiseptics. 
In  dark  moist  places,  especially  in  membranes  or  in  mucus,  it  remains 
alive  for  months  while  it  dies  in  a  few  hours  in  bright  sunlight.  On  the  in- 
fected organism  it  is  found  in  the  exudative  membrane  of  the  necrotic  tissue. 
Later  it  occurs  in  the  neighboring  lymph  nodes  and  may  also  be  found  in 
the  lungs,  the  cerebrospinal  fluid,  in  the  blood  and  occasionally  in  the  urine. 

After  the  disappearance  of  the  false  membrane,  the  bacillus  may  usually 
be  found  for  several  days  on  the  surface  of  the  membranes,  which  have 
again  become  normal.  At  times  it  may  even  be  present  for  many  weeks. 
Not  infrequently  the  germ  is  found  in  the  pharynx  of  healthy  persons  and 
especially  in  those,  who  are  in  close  contact  with  a  case  of  diphtheria.  These 
persons  are  termed  carriers.  The  short  pseudodiphtheria  bacillus  is  closely 
related  (p.  658). 

This  pseudo  form  frequently  lives  in  the  nose  and  throat  of  healthy 
persons  and  morphologically  and  biologically  shows  gradual  transition 
stages  to  the  true  diphtheria  bacillus.  It  is,  however,  always  a  virulent  for 
the  guinea  pig,  which  is  killed  by  infection  with  the  true  diphtheritic  type. 

Diphtheria  is  usually  spread  from  one  person  to  another.  Its  origin  is 
often  obscure,  since  the  infection  may  come  from  convalescent  or  healthy 
bacillus  carriers. 

Since  the  bacillus  lives  almost  exclusively  in  the  nose  and  mouth,  the 
possibility  of  transmission  in  the  act  of  kissing  is  very  imminent  and  the 
danger  of  its  spread  from  infected  children  by  contamination  of  hands,  bed- 
ding or  clothing  with  the  secretions  of  the  mouth  or  nose  is  especially  great. 
Indirect  transmission  by  means  of  handkerchiefs,  toys  etc.,  is  not  at  all 
uncommon.  Filth  and  a  lack  of  personal  cleanliness  are  active  agents  in 
the  spread  of  the  disease.  Accordingly  the  cleaner  children  of  the  well-to- 
do  are  less  frequently  affected  than  those  in  poorer  circumstances  and  there 
is  a  certain  justification  in  designating  diphtheria  as  a  dirt  disease.  The 
large,  heavy  diphtheria  bacilli  are  obviously  not  very  readily  diffused  and 


639 

usually  require  contact  for  transmission.  Nevertheless  droplet  infection 
is  quite  a  conceivable  thing  in  the  event  of  severe  coughing  and  sneezing, 
and  particularly  with  nasal  diphtheria. 

As  a  rule  the  bacilli  reach  the  port  of  entry  through  the  mouth,  conveyed 
to  it  by  the  fingers  or  on  the  food.  They  develop  primarily  on  the  faucial 
or  pharyngeal  tonsil. 

Cases  are  most  numerous  between  the  ages  of  two  and  five.  After  the 
tenth  year  the  disease  is  uncommon  and  but  few  adults  are  affected.  In 
fact  adults  are  affected  only  in  severe  epidemics.  Cases  occurring  in  in- 
fancy are  infrequent,  probably  because  the  adenoid  organs  of  the  pharynx 
are  immature  at  this  period  of  life.  It  is  not  to  be  supposed,  however,  that 
young  infants  escape  entirely.  They  are  affected  chiefly  with  nasal  diphtheria. 

The  general  predisposition  to  the  disease  is  not  nearly  so  great  as  toward 
measles  or  pertussis;  many  persons  never  have  diphtheria  even  though  they 
are  exposed  to  infection  and  have  never  had  the  disease.  (See  page  574.) 

Susceptibility  depends  upon  many  factors.  For  some  unknown  cause 
certain  individuals  show  a  greater  predisposition  than  others.  This  predis- 
position usually  increases  during  periods  when  the  mucous  membranes  most 
liable  to  infection  are  in  a  catarrhal  or  inflammatory  state,  particularly  in 
cold  seasons  and  during  transitional  periods.  This  affords  explanation  of 
the  chief  prevalence  of  affections  of  the  larynx  and  bronchi  during  those 
months,  when  catarrh  is  common  and  of  the  more  sporadic  appearance  of 
pharyngeal  diphtheria  during  the  summer  and  fall.  The  individual  predis- 
position is  determined  by  the  presence  of  irritable  mucous  membranes  and 
of  adenoid  vegetations.  Children  with  a  lymphatic  habitus  are  affected 
more  readily  than  those  who  are  free  from  this  constitutional  anomaly. 
These  children  also  offer  less  resistance  to  the  disease  than  do  normal  types. 

In  certain  cases  it  is  often  extremely  difficult  or  quite  impossible  to 
determine  the  extent  to  which  either  the  inherent  predisposition  of  patient 
or  the  intensity  of  virulence  in  the  infective  organism  is  responsible  for  a 
given  attack  of  the  disease.  The  character  of  an  epidemic  is  doubtless  de- 
termined in  a  general  way  by  the  virulence  of  the  bacillus. 

It  is  not  definitely  known  whether  a  single  attack  of  the  disease  confers 
immunity.  It  is  undoubtedly  much  less  permanent  than  is  generally 
supposed,  for  second  and  even  third  attacks  are  not  at  all  rare.  It  is 
evidently  a  question  rather  of  immunity  to  toxin,  than  of  immunity  to 
bacteria,  since  individuals  recovering  from  diphtheria  often  carry  virulent 
diphtheria  bacilli  for  a  long  time  without  being  affected  by  their  presence. 
Recurrences,  too,  often  after  three  or  four  weeks  are  especially  common  in 
patients  who  have  been  treated  with  serum,  taking  place  at  the  time  when 
the  passive  immunity  loses  its  power. 

The  Schick  Reaction. — Schick  has  published  a  method  by  which  the 
natural  presence  of  antitoxin  in  the  blood  and  tissues  can  be  determined 
very  easily.  A  standard  diphtheria  toxin  is  diluted  with  normal  saline  to 
such  a  strength,  that  K'o  c.c.  or  21o  c.c.  contains  K'o  M.  L.  D.  for  the 
guinea  pig.  This  amount  is  injected  intracutaneously  on  the  flexor  surface 
of  the  arm.  The  explanation  of  the  test  is  that  when  no  antitoxin  is  present, 


640 


TEXT-BOOK  OF  PEDIATRICS 


the  toxin  acts  on  the  skin  and  produces  in  from  24  to  36  hours  a  circum- 
scribed area  of  redness  and  slight  infiltration,  which  measures  from  1  to  2 
cm.  in  diameter.  It  persists  from  seven  to  fifteen  days  and  on  fading  shows  a 
superficial  scaling  and  a  persistent  brownish  pigmentation.  This  is  called  a 
positive  Schick  reaction  and  indicates  that  the  individual  is  susceptible  to 
infection  with  the  diphtheria  bacillus.  Pseudo-reactions  are  rather  fre- 
quent in  adults.  They  appear  earlier,  are  more  edematous,  usually  of 
greater  diameter  and  disappear  in  from  24  to  72  hours  without  leaving  the 
characteristic  desquamation  and  pigmentation.  They  can  be  obtained  with 
neutralized  or  heated  toxin  and  in  certain  individuals  with  dilutions  of  plain 
broth.  According  to  Park  and  Zingher  the  percentage  of  positive  Schick 
reactions  at  varying  age  periods  is  briefly  as  follows: 

POSITIVE  SCHICK  REACTIONS 


Years. 

Per  Cent. 

Years. 

Per  Cent. 

Years. 

Per  Cent. 

1-2 
2-4 
4-6 

50-70 
32-60 
25-55 

6-8 
8-10 
10-12 

21-55 
22-55 
21-50 

12-14 
14-16 
16-30 

17-50 
16-50 
15-40 

Toxin  Antitoxin  Inoculations. — Theobald  Smith  made  a  careful  study 
of  the  production  of  an  immunity  against  the  diphtheria  toxin  in  guinea 
pigs  by  the  use  of  toxin  antitoxin  mixtures.  He  suggested  the  use  of  such 
mixtures  in  children  for  practical  immunization.  Behring  brought  about 
the  practical  application  of  this  method.  Park  and  Zingher  in  this  country 
immunized  4000  cases  by  inoculating  toxin  antitoxin  mixtures  (66-70  per 
cent.  L+  to  each  unit  of  antitoxin  or  80-90  per  cent.  L+  to  each  unit  of  anti- 
toxin). They  obtained  the  best  results  by  giving  three  injections  at  weekly 
intervals.  No  harmful  after  effects  were  noted  and  according  to  their  latest 
reports  these  toxin  antitoxin  injections  produced  permanent  immunity  in 
about  90  per  cent,  of  the  non-immunes.  Based  on  the  Schick  reaction  30-40 
per  cent,  became  immune  three  weeks  after  the  first  injection,  about  50  per 
cent,  at  four  weeks,  70-80  per  cent,  at  six  weeks  and  85-90  per  cent,  at  from 
eight  to  twelve  weeks.  The  duration  of  the  active  immunity  as  evidenced 
by  continued  negative  Schick  reactions  has  persisted  for  over  four  years. 

A  pronounced  and  dangerous  predisposition  to  diphtheria  of  the  respir- 
atory passages  is  caused  by  measles.  (See  page  612) 

During  recent  decades  sporadic  cases  of  diphtheria  have  constantly 
occurred  in  most  countries.  Frequently,  however,  distinct  epidemics  ap- 
pear. In  a  general  way  it  may  be  said,  that  the  severity  of  the  disease 
and  the  activity  of  its  contagious  quality  increase  with  the  multiplication 
of  the  cases.  The  origin  of  these  epidemics  is  still  \vholly  obscure.  Over 
long  periods  of  time,  which  may  indeed  cover  many  decades,  the  number  of 
cases  may  gradually  increase  from  year  to  year,  until  there  develops  a 
widespread  and  terrible  epidemic,  after  which  long  periods  again  elapse  in 
which  only  sporadic  cases  appear.  In  Germany  there  has  been  a  general 
decrease  of  diphtheria  during  the  last  twenty  years  without  diminishing  the 


641 

fact,  that  epidemics  of  greater  or  less  severity  still  occur  in  single  cities  or 
villages,  as  was  seen  in  Hamburg  in  1909  and  1910. 

A  seasonal  influence  is  usually  distinctly  noticeable  in  the  appearance  of 
sporadic  cases.  It  has  been  shown,  that  the  cold  months  are  especially  favor- 
able to  the  disease.  Indeed,  cold  dry  winds  often  cause  a  marked  increase 
of  cases  of  croup.  Epidemics  may  occur,  however,  during  the  summer. 

PATHOGENESIS  AND  PATHOLOGIC  ANATOMY 

The  growth  of  the  diphtheria  bacillus  on  the  mucous  membrane  first 
produces  a  swelling  and  necrosis  of  the  epithelial  cells  as  a  result  of  the 
action  of  the  poison  extruded  by  them.  The  deeper  action  of  the  diphtheria 
toxin  causes  an  inflammation  of  the  capillaries  in  the  immediate  neighbor- 
hood with  resulting  infarct  formation  and  the  excretion  of  fibrin.  This 
fibrin  passes  into  the  necrotic  epithelium  and  with  it  forms  the  white  exu- 
date,  which  constitutes  the  diphtheritic  membrane.  In  it  are  also  found 
emigrant  round  cells.  Depending  upon  the  depth  to  which  the  toxin  pene- 
trates are  the  macroscopic  results.  An  exudate  in  the  epithelium  and  a 
loose  pseudomembrane  upon  the  mucosa,  anatomically  termed  croupous, 
are  formed  if  the  process  be  a  superficial  one.  It  includes  the  deeper  layers 
of  the  mucosa  resulting  in  a  firm  inlay  anatomically  termed  diphtheritic  if 
the  process  is  deep.  Upon  the  surface  of  the  mucous  membrane  are  found 
various  saprophytes,  staphylocci,  streptococci,  etc.,  associated  with  the 
diphtheria  bacillus  and  making  up  the  detritus.  In  the  deeper  portions  of 
the  membrane,  which  contains  larger  quantities  of  fibrin,  are  found  only 
diphtheria  bacilli  and  markedly  degenerated  and  necrotic  epithelial  cells. 
Below  this  is  seen  a  fibrin  layer  containing  numerous  leucocytes  and  very 
slightly  altered  epithelium.  Thence,  the  bacilli  reach  the  neighboring 
lymph  nodes  but  they  very  rarely  get  into  the  blood,  so  that  most  of  the 
disturbance  of  the  general  organism  must  be  considered  the  result  of  the 
action  of  the  toxin.  If  the  toxin  affects  the  deeper  structures,  necroses  of 
the  entire  mucous  membrane  may  result.  Such  necroses  heal  by  second 
intention  with  scar  formation. 

Aside  from  the  mucous  membranes,  the  heart  and  the  peripheral  nerves 
are  most  frequently  affected. 

At  autopsy  the  heart  is  found  in  diastole  and  usually  shows  marked 
myocardial  changes.  The  cardiac  muscle  is  bluish-gray,  is  friable,  containing 
fat  globules,  and  shows  marked  parenchymatous  degeneration  and  fre- 
quently disappearance  of  striation.  According  to  Eppinger,  a  degenera- 
tion of  the  myocardium,  resulting  in  a  characteristic  dissolution  of  the 
muscle  fibre,  is  frequently  seen.  This  finding  is  denied,  however,  by  others. 
Serious  degeneration  of  the  muscle  nuclei  is  often  found  following  the  car- 
diac death  of  diphtheritics. 

In  cardiac  death  the  vagus  nerve  often  shows  marked  changes,  especially 
in  the  destruction  of  the  nerve  sheaths,  in  the  atrophy  of  the  axis  cylinders 
and  in  a  small  cell  infiltration.  Similar  degeneration  is  demonstrable  in  the 
various  nerves  affected  in  peripheral  paralysis.  In  the  spinal  cord  distinct 
changes  are  usually  lacking. 
41 


642  TEXT-BOOK  OF  PEDIATRICS 

Roemheld  was  able  to  demonstrate  in  a  case  of  diphtheritic  paralysis  of 
an  adult,  an  increase  of  protein  in  the  cerebrospinal  fluid,  an  increase  which 
the  writer  has  found  quite  regularly  in  hospital  cases  of  children  with  simi- 
lar paralysis.  This  is  evidence,  at  least,  of  a  toxic  irritation. 

THE  GENERAL  DISEASE-PICTURE 

The  course  of  diphtheria  is  extremely  variable,  depending  upon  its  local- 
ization, the  virulence  of  the  infection  and  the  individual  predisposition. 
The  commonest  and  mildest  form  is  confined  to  the  tonsils.  This  localized 
form  has  a  moderate  course  in  the  majority  of  cases,  but  it  may  develop  a 
severe  toxicity  and  result  fatally.  In  other  cases  there  is  a  tendency  to 
involve  large  areas,  the  membrane  formation  spreading  to  the  palate,  the 
pharynx  and  even  to  the  nose,  larynx  and  trachea.  The  malignancy  of  the 
disease,  however,  is  not  always  in  direct  ratio  to  the  extent  of  its  spread, 
although  those  cases  in  which  the  membrane  is  confined  to  the  tonsils  are  as  a 
rule  either  in  themselves  or  by  aid  of  the  antidiphtheritic  serum  more  benign. 

In  order  to  facilitate  description  one  may  consider  a  case  of  medium 
severity  and  add  to  it  the  peculiarities  and  complications  of  the  course. 
The  incubation  period  is  not  constant.  It  usually  lasts  from  two  to  four 
days;  at  least  this  is  the  length  of  time  which  elapses  before  second  cases 
appear  in  an  infected  family. 

The  onset  of  the  disease  is  usually  attended  by  general  symptoms.  The 
child  becomes  pale  and  listless,  has  a  poor  appetite,  sometimes  vomits  and 
complains  of  headache.  The  older  child  may  refer  to  the  pain  in  swallowing, 
even  at  this  time.  The  physician,  called  perhaps  the  next  day,  finds  the 
temperature  ranging  from  '38°-39°C.  (100°-102°  F.),  a  rapid'  pulse  and 
pronounced  malaise.  A  slight  swelling  of  the  submaxillary  nodes,  which 
are  painful  upon  pressure  and  a  marked  fetor  ex  ore,  which  the  mother  has 
noticed,  lead  the  physician  to  inspect  the  throat,  even  though  the  patient 
may  not  complain  of  pain.  The  tongue  has  a  white  coating.  Both  tonsils 
are  moderately  enlarged  and  reddened.  Upon  one  or  both  a  white  spot  is 
seen  covering  a  third  or  half  of  the  surface.  This  white  deposit  cannot  be 
wiped  away  with  a  cotton-covered  applicator  but  may  be  removed  with  a 
forceps  and  is  found  to  be  a  rather  firm  elastic  membrane.  If  the  physician 
sees  the  case  very  early,  he  finds  merely  an  ordinary  and  moderate  tonsillar 
angina,  or  a  fine  veil-like  exudate  over  the  tonsils.  By  the  next  day  the  red- 
dening and  swelling  of  the  tonsils  has  increased.  The  membrane  has  be- 
come thicker  and  more  extensive  and  may  cover  the  entire  surface  of  both 
tonsils  (Fig.  164).  Frequently  the  process  stops  at  this  point.  Usually 
however,  one  or  more  follicles  on  the  visible  or  posterior  wall  of  the  pharynx 
become  covered  with  the  white  exudate  at  about  the  same  time.  From 
these  follicles  the  membrane  gradually  spreads  until  it  covers  the  entire 
pharynx.  Within  four  or  five  days  the  process  has  often  extended  so  that 
the  soft  palate,  the  uvula,  both  tonsils,  and  a  part  of  the  phan^nx  are  cov- 
ered and  its  maxinal  point  has  been  reached. 

In  the  meanwhile  the  swelling  and  redness  of  the  tonsils  and  the  soft 
palate  has  increased.  The  tonsils  almost  touch  in  the  median  line  and  pre- 


THE  ACUTE  INFECTIOUS  DISEASES 


643 


vent  closer  inspection  of  the  pharynx.  The  difficulty  of  examination  is 
increased  by  the  fact,  that  the  inflamed  parts  are  covered  by  a  mucopuru- 
lent  secretion. 

The  swelling  of  the  fauces  and  pharynx  causes  difficulty  in  breathing 
and  snoring  and  mouth-breathing  result.  The  odor  from  the  mouth,  a 
sickly  glue-like  smell,  is  aggravated  and  may  be  noticed  at  a  distance. 
Mucus  and  saliva  flow  from  the  open  mouth.  The  swelling  of  the  submaxil- 
lary  nodes  becomes  more  marked  and  may  be  visible.  Palpation  reveals 
separate  nodes  the  size  of  a  cherry.  These  are  moderately  sensitive,  but 
there  is  no  inflammation  of  the  peri- 
nodular  tissue. 

The  general  condition  of  the  patient 
grows  worse  from  day  to  day.  The  tem- 
perature varies  from  38.5°  to  39.5°  C. 
(101°-103°  F.).  Marked  morning  re- 
missions may  occur,  ranging  almost  to 
normal  or  it  may  drop  after  the  first 
two  or  three  days.  The  pulse  is  rapid, 
running  from  100  to  180  according  to 
the  patient's  age.  It  is  small  and  com- 
pressible. The  face  shows  an  increasing 
pallor,  with  deep  shadows  under  the 
eyes.  The  child  looks  tired  and  ill. 
His  appetite  is  completely  lost  and  it 
is  extremely  difficult  even  to  force  him 
to  take  any  nourishment  at  all,  on 
account  of  the  pain  of  swallowing. 
Sleep  is  disturbed  and  often  interrupted 
by  the  difficulty  in  breathing,  result- 
ing from  the  swelling  and  the  exces- 
sive secretion. 

Examination  of  the  internal  organs 
reveals  no  special  changes.  The  lungs 
remain  normal.  In  the  heart  low  systolic  murmurs  are  occasionally  heard 
over  the  mitral  and  over  the  pulmonic.  The  spleen  and  the  liver  are 
slightly  enlarged. 

The  urine  frequently  contains  a  moderate  quantity  of  albumen  and  casts 
after  the  third  day. 

In  previously  healthy  children  and  especially  in  those  in  later  childhood, 
the  disease  often  abates  from  the  fourth  to  the  seventh  day.  The  membrane 
may  have  been  confined  to  the  tonsils  alone  or  the  soft  palate  and  the  phar- 
ynx may  have  been  included.  With  the  arrest  of  the  disease  the  fever  begins 
to  recede.  The  membrane  begins  to  loosen  around  the  edges  and  is  sepa- 
rated gradually  or  in  large  shreds.  The  throat  is  clear  within  eight  or  ten 
days.  The  swelling  of  the  lymph  nodes  and  the  albuminuria  disappear 
within  the  same  period.  The  resulting  anemia  requires  a  little  longer  for 


FIG.    164 — Diphtheritic    exuclate    on    both 
tonsils.    (Right  tonsil  not  entirely  covered) . 


644  TEXT-BOOK  OF  PEDIATRICS 

recovery.    Similarly  the  irregularity  of  the  heart  action,  the  small  pulse  and 
the  easy  exhaustion  may  persist  for  some  time. 

Not  infrequently,  however,  the  disease  terminates  fatally  in  a  week,  or 
two.  This  outcome  may  be  due  to  the  further  spread  of  the  infection  to 
the  mucous  membranes  of  the  nose,  the  larynx  and  trachea  and  broncho- 
pneumonia  and  myocarditis  may  ensue  with  the  increasing  toxicity. 

Because  of  these  serious  dangers,  we  no  longer  await  a  spontaneous 
recovery  from  diphtheria,  but  we  proceed  at  once  to  the  injection  of  anti- 
diphtheritic  serum.  This  treatment  is  certain  to  shorten  the  course  of  the 
disease  and  to  limit  its  local  spread.  If  a  sufficient  quantity  of  antitoxin, 
say  from  5000  to  10,000  units  is  administered  in  cases  of  the  degree  of  severity 
described,  it  may  be  certainly  expected,  that  the  local  infection  will  not 
spread  materially.  This  will  be  especially  true  in  cases  where  the  toxins 
have  had  their  necrotic  effect,  but  in  which  the  fibrin  has  not  yet  invaded 
the  tissues.  Certainly  within  twenty-four  hours  after  the  use  of  the  anti- 
toxin, further  exudation  ceases  and  a  sharp  zone  of  demarcation  appears 
around  the  membranous  area.  The  membrane  itself  becomes  spongy  and 
loosens  up  around  the  edges.  It  separates  in  large  lamellae  and  is  completely 
disposed  of  in  three  or  four  days.  The  temperature  falls  within  twenty- 
four  hours  and  the  general  condition  rapidly  improves.  Many  a  child  to 
whom  the  antitoxin  is  given  early  will  appear  quite  well  and  will  sit  up  and 
play  within  a  day  or  two. 

In  too  many  cases,  however,  the  disease  presents  a  course  quite  variant 
to  that  of  the  moderate  type  described.  It  may  be  of  even  milder,  or  of  far 
more  malignant  character,  or  it  may  be  characterized  by  peculiar  localiza- 
tions of  the  disease  process. 

MILD  FORMS 

Among  older  children,  in  ordinary  times  a  large  proportion  of  cases  are 
very  mild.  The  tonsils  will  show  only  a  small  membrane.  The  tempera- 
ture does  not  exceed  38°-38.5°  C.  (100°-101°  F.)  The  general  health  is  but 
slightly  impaired.  The  membrane  is  thrown  off  within  three  to  five  days 
and  in  a  week  or  ten  days  the  patient  has  completely  recovered.  Occasion- 
ally cases  are  observed  that  are  even  more  mild  than  this.  In  a  few  crypts 
of  the  slightly  inflamed  tonsils,  small,  elongated,  whitish-gray  patches, 
the  size  of  a  pinhead  or  a  little  more  are  formed,  giving  a  picture  of  simple 
lacunar  angina.  There  is  very  little  rise  of  temperature.  Nevertheless, 
these  small  exudates  do  not  have  the  soft,  cheesy  character  of  the  ordinary 
lacunar  angina,  but  consist  of  light,  but  firmly  adherent  membranes  in 
which  diphtheria  bacilli  may  be  demonstrated.  The  diphtheritic  nature  of 
these  lacunar  exudates  may  sometimes  be  recognized  clinically,  particularly 
when  they  become  confluent  and  form  a  single  mass  membrane  which  may 
spread  to  the  uvula  and  the  pharynx.  They  are  also  readily  recognized 
when  a  severe  laryngeal  croup  develops  or  when  paralysis  follows  the  seem- 
ingly mild  angina.  Not  infrequently  true  diphtheria  takes  a  course  resembling 
a  harmless,  catarrhal  angina.  In  this  form  the  clinical  diagnosis  is  impos- 
sible and  diphtheria  is  only  suspected,  when  it  occurs  chiefly  in  families  or 


THE  ACUTE  INFECTIOUS  DISEASES  645 

hospitals  where  more  severe  forms  appear.  A  bacteriologic  examination 
reveals  the  true  nature  of  the  disease.  These  cases  are  especially  dangerous 
because  they  are  often  neglected  and  in  the  absence  of  proper  precaution 
spread  the  disease. 

SEVERE  FORMS 

Unfortunately  one  may  never  be  certain,  that  a  seemingly  mild  case  of 
diphtheria  may  not  and  very  suddenly  pass  into  a  serious  one.  The  grave 
farms,  of  course,  are  usually  severe  at  the  onset.  A  child,  usually  of  over 
three  years  of  age,  suddeny  becomes  ill  with  high  fever,  vomiting  and  head- 
ache and  wants  to  go  to  bed.  The  older  child  may  complain  of  sore  throat 
and  of  pain  in  the  abdomen.  In  contrast  to  the  usual  forms  the  tonsils  are 
intensely  red  and  swollen.  Even  on  the  first  day  both  tonsils  are  covered 
with  a  large,  discolored,  pasty  or  membranous  exudate.  At  the  same  time 
or  by  the  second  day  the  uvula  and  the  soft  palate  are  covered.  The  swell- 
ing of  the  tonsils  is  so  great  that  no  room  is  left  for  the  enlarged  uvula  and 
inspection  of  the  pharynx  often  becomes  impossible,  a  difficulty  increased 
by  the  excessive  secretion  of  mucus.  If  the  posterior  pharyngeal  wall  can 
be  seen,  it  will  also  be  found  covered  with  membrane  by  the  second  or  third 
day.  The  extreme  swelling  of  the  tonsils  and  the  entire  throat  makes  swal- 
lowing almost  impossible;  the  speech  becomes  difficult,  nasal  breathing  is 
obstructed,  so  that  the  patient  is  forced  to  breath  through  the  mouth,  from 
which  a,  terrible  fetor  arises  and  from  which  flows  a  thin  and  often  sanguin- 
eous secretion.  The  nasal  respiration  is  further  obstructed  on  account  of 
the  swelling  of  the  mucous  membrane  of  the  posteror  nares  or  of  the  entire 
nasal  chambers,  which  are  often  involved  in  the  diphtheria  process.  The 
respiration  is  labored  and  deep,  even  when  the  lung  findings  are  negative. 
Should  the  disease  continue  for  more  than  five  to  seven  days,  large  broncho- 
pneumonia  foci  are  often  found.  The  lateral  cervical  nodes  are  markedly 
enlarged  and  the  swelling  soon  extends  to  the  peri-nodular  tissue.  This 
marked  infiltration  of  both  sides  may  extend  to  the  median  line,  giving  the 
neck  an  unusually  plump  appearance. 

Cases  in  which  hemorrhage  occurs  are  fortunately  rare,  for  they  give  a 
very  bad  prognosis.  While  it  usually  arises  from  the  infected  surfaces,  ep- 
istaxis  or  even  petechial  hemorrhages  in  the  skin  may  be  observed. 

The  general  health  disturbance  is  severe  from  the  first.  The  child  is 
apathetic ,  his  eyes,  surrounded  by  dark  circles,  remain  wide  open,  while  an 
anxious,  drawn  expression  marks  his  alarmingly  pallid  face.  At  intervals 
great  restlessness  obtains.  The  appetite  disappears  and  although  tortured 
with  thirst  he  is  hardly  able  to  swallow  fluids.  The  fever  often  runs  high, 
ranging  from  39°-40.5°  C.  (102°-105°  F.)  during  the  first  few  days  per- 
haps receding  later  and  often  remittent  in  type.  Yet  even  in  very  severe 
cases  there  may  be  no  fever,  so  that  temperature  is  no  criterion  of  the  grav- 
ity of  the  disease.  The  pulse  from  the  first  is  small,  frequent,  very  com- 
pressible. Even  by  the  second  day,  it  may  hardly  be  palpable,  unless 
marked  improvement  can  be  secured  by  the  use  of  stimulants.  The  extrem- 
ities frequently  become  cold  and  cyanotic. 


646  TEXT-BOOK  OF  PEDIATRICS 

The  heart  often  shows  no  distinct  objective  changes  aside  from  quite 
feeble  heart  sounds.  The  first  sound  at  the  apex  is  sometimes  replaced  by 
a  murmur.  After  several  days  cardiac  dilatation  and  a  coincident  painful 
enlargement  of  the  liver  may  appear. 

The  spleen  is  usually  enlarged  also  but  on  account  of  its  softness  the 
swelling  is  frequently  undemonstrable  in  the  living  subject.  Signs  of  ne- 
phritis are  always  found  in  the  urine  but  the  symptoms  of  this  complication 
never  become  prominent. 

In  the  severe  types  of  diphtheria  already  described  masses  of  strepto- 
cocci are  sometimes  found  associated  with  the  diphtheria  bacilli  in  the 
discolored  and  at  times  gangrenous  membranes  'of  this  so-called  septic 
diphtheria.  Since  streptococci  are  constant  inhabitants  of  the  oral  cavity  and 
their  increase  may  be  predicated  in  every  inflammatory  condition  affecting 
it,  it  follows  that  they  may  be  found  in  large  numbers  in  every  case  of  diph- 
theria. In  this  septic  form  of  diphtheria  they  are  not  always  so  very  abun- 
dant, so  that  we  must  still  suppose  that  its  serious  symptoms  are  essentially 
traceable  to  the  diphtheria  bacillus.  It  is  better  therefore  to  use  Heubner's 
designation  of  malignant  diphtheria  rather  than  the  term  septic. 

If  these  cases  are  not  treated  with  large  doses  of  antitoxin  from  the  very 
onset  of  the  attack,  they  usually  die  by  the  end  of  the  first  or  the  beginning 
of  the  second  week,  after  showing  signs  of  cardiac  weakness,  of  intoxication 
or  of  severe  broncho-pneumonia.  The  disease  does  not  spread  to  the  larynx 
and  trachea  as  often  as  it  does  in  the  milder  forms,  but  nasal  diphtheria 
may  be  present  from  the  very  beginning.  Early  serum  treatment  may  save 
a  large  per  cent,  of  the  malignant  cases.  It  is  true,  even  then,  that  the  out- 
look is  not  very  bright  for  children  under  five  years. 

If  recovery  does  set  in  the  membranes  will  disappear  about  the  end  of 
the  first  week,  but  ulcers  are  frequently  exposed,  especially  on  the  uvula, 
which  require  a  longer  time  to  heal.  Convalescence  is  very  gradual  and 
may  occupy  many  weeks.  During  all  this  time  cardiac  weakness  may  still 
threaten  a  fatal  termination.  Sporadic  cases,  which  cannot  be  saved  despite 
the  employment  of  antitoxin  on  the  first  day,  are  still  occasionally  seen  but 
fortunately  they  are  now  very  rare.  In  such  instances,  blame  for  the  fatality 
is  to  be  laid  not  only  to  an  unusual  degree  of  virulence  of  the  diphtheria 
bacillus,  but  also  to  an  extraordinary  susceptibility,  either  local  or  general, 
in  the  individual.  When  death  occurs  within  the  first  few  days,  it  is  usually 
preceded  by  signs  of  cardiac  weakness.  When  it  occurs  later,  evidences  of 
nephritis  are  commonly  added.  The  rare  cases  in  which  gangrene  develops 
and  changes  the  diphtheritic  patches  to  discolored  brownish  readily  bleed- 
ing masses  which  give  a  cadaverous  odor,  are  always  serious  and  almost 
always  fatal. 

SPECIAL  LOCALIZATIONS  or  DIPHTHERITIC  MEMBRANES 

The  most  common  form  of  diphtheria  begins,  as  already  suggested,  upon 
the  tonsils  and  may  extend  to  the  fauces  and  the  pharynx.  From  these 
parts  the  disease  frequently  spreads  to  other  surfaces,  which  may  indeed  be 
primarily  affected.  This  often  results  in  great  diagnostic  difficulties. 


THE  ACUTE  INFECTIOUS  DISEASES  647 

NASAL  DIPHTHERIA 

The  spread  of  diphtheria  to  the  nose  is  quite  common  and  all  the  more 
so  the  younger  the  child.  The  exudate,  usually  appearing  first  on  the  ton- 
sils or  in  the  pharynx  creeps  up  along  the  lateral  pharyngeal  pillars  or  over 
the  superior  surface  of  the  soft  palate  to  the  posterior  nares  and  thence  to 
the  nasal  chambers.  Often,  however,  the  pharynx  remains  free  and  symp- 
toms of  nasal  diphtheria  manifest  themselves  very  quickly  after  the  appear- 
ance of  the  disease  on  the  tonsils.  This  may  be  readily  understood,  since 
the  exudate  may  creep  up  the  posterior  surface  of  the  tonsils,  where  it  can- 
not be  seen  and  since  in  tonsillar  diphtheria  the  inflamed  pharynx  always 
contains  diphtheria  bacilli. 

The  onset  of  nasal  diphtheria  is  not  easily  determined.  At  first  there  is 
evidence  of  difficult  nasal  breathing  due  to  the  swelling  in  the  region  of  the 
posterior  nares.  An  obstructed  snoring  breathing  may  frequently,  however, 
be  the  result  of  stenosis  of  the  pharynx  resulting  from  enlargement  of 
the  tonsils  and  the  pharyngeal  structures.  Only  when  a  slightly  purulent 
fluid  flows  from  the  nose,  at  first  often  of  unilateral  appearance,  may  one 
be  certain  that  there  is  nasal  diphtheria.  As  compared  with  that  of  ordinary 
coryza  the  secretion  contains  less  mucus  and  is  often  stained  a  brownish  or 
reddish  color;  it  erodes  the  nostrils  and  the  upper  lip.  The  nose  very  soon 
becomes  obstructed.  Upon  close  inspection  the  ake  of  the  nose  and  the 
surrounding  tissue  are  seen  to  be  markedly  swollen,  injected  and  covered 
in  large  areas  with  a  dried  secretion.  Frequently  no  membrane  is  visible, 
its  formation  usually  beginning  at  the  choana  and  not  extending  very  far 
forward.  Consequently,  in  the  case  of  small  children,  it  cannot  be  discerned 
without  the  use  of  a  speculum,  with  an  attendant  to  hold  the  child  during 
the  examination.  At  times,  however,  the  exudate  extends  so  far  forward, 
that  it  can  be  detected  by  simple  inspection  or  with  the  aid  of  a  reflected 
light,  on  the  alse  nasi  or  the  septum.  Sometimes  pieces  of  the  membrane 
are  forced  out  by  sneezing  or  can  be  removed  with  the  forceps. 

At  the  onset  of  nasal  diphtheria  the  submaxillary  lymph  nodes  become 
more  markedly  swollen.  The  parts  surrounding  the  nose  may  be  edematous 
and  reddened  by  an  erysipeloid  inflammation. 

If  nasal  diphtheria  is  consequent  upon  or  accompanies  pharyngeal  diph- 
theria it  usually  causes  no  new  symptoms,  but  simply  aggravates  existing 
conditions  and  may  lead  to  an  increase  of  fever.  It  makes  the  prognosis 
much  more  grave  and  favors  the  development  of  such  secondary  infections 
as  broncho-pneumonia  or  sepsis. 

Not  infrequently,  however,  nasal  diphtheria  is  primary  and  presents 
the  only  localization  of  the  disease.  Unless  the  case  occurs  during  an  epi- 
demic the  actual  condition  is  easily  overlooked  and  a  diagnosis  is  made 
only  when  a  pharyngeal  membrane  or  a  membranous  croup  develops  or 
when  the  serious  condition  of  the  child's  general  health  indicates,  that  the 
case  is  other  than  one  of  simple  coryza.  In  such  an  event  the  use  of  anti- 
toxin often  comes  too  late,  for  nasal  diphtheria  is  under  all  circumstances  a 
very  dangerous  condition  and  its  early  diagnosis  is  extremely  important. 


648  TEXT-BOOK  OF  PEDIATRICS 

It  follows,  that  every  febrile  coryza  with  which  there  is  marked  constitu- 
tional disturbance,  in  which  there  is  an  enlargement  of  the  submaxillary 
nodes  and  in  which  a  thin  fetid  purulent  or  even  blood-stained  erosive  dis- 
charge is  present  flowing  from  one  or  both  nostrils,  should  arouse  suspicion 
of  diphtheria.  This  is  especially  true  during  an  epidemic  of  diphtheria  or 
when  there  are  other  cases  of  the  disease  in  the  house. 

Primary  nasal  diphtheria  is  especially  common  in  infancy.  Indeed  it  is 
almost  the  only  form  of  diphtheria  observed  among  infants  during  their 
first  few  months.  Great  difficulty  is  often  experienced  in  recognizing  it, 
since  one  cannot  depend  upon  the  formation  of  visible  membranes  and  the 
bacteriologic  diagnosis  presents  some  special  obstacles.  It  is  to  be  remem- 
bered that  it  is  common  among  infants  to  find  virulent  diphtheria  bacilli  in 
ordinary  coryza  or  even  upon  apparently  normal  mucous  membranes.  In 
such  cases  one  must  constantly  be  on  guard.  Particularly  among  infants 
cases  of  simple  coryza  are  not  infrequently  to  be  found,  which  do  not  affect 
the  general  health,  but  in  which  diphtheria  bacilli  can  be  demonstrated 
and  upon  which  a  fatal  nasal  diphtheria  develops  rapidly  after  several 
weeks  of  gradually  increasing  fever. 

Cases  of  obstinate  rhinitis  in  children  of  exudative  and  scrofulous  dia- 
thesis often  resemble  nasal  diphtheria  at  certain  points.  There  is  a  puru- 
lent discharge,  the  erosive  quality  of  which  may  lead  to  the  development  of 
ulcers  upon  the  skin  or  mucous  membrane  of  the  alae  nasi  and  the  upper 
lip.  These  ulcers  may  be  covered  with  a  membrane  similar  to  that  which 
appears  on  such  erosions  in  nasal  diphtheria.  In  such  cases  a  bacteriologic 
examination  alone  will  determine  a  diagnosis. 

In  later  childhood  rare  instances  are  seen  of  a  purely  local  disease,  a 
membranous  rhinitis,  which  may  last  for  several  weeks  or  even  months. 
In  these  cases  the  diphtheria  bacillus  is  usually  absent,  although  the  so- 
called  pseudodiphtheria  bacillus  may  be  found.  Since  such  a  long  persist- 
ing rhinitis  with  these  diphtheroid  bacilli  present  may  produce  true  serious 
diphtheritic  infections,  which  may  be  conveyed  by  contact  to  other  persons, 
it  is  well  to  treat  it  as  true  diphtheria. 

AURAL  DIPHTHERIA 

In  young  children,  diphtheria  of  the  pharynx  or  more  often  of  the  nose, 
may  cause  an  otitis  media.  Oftentimes  this  results  in  a  perforation  of  the 
membrana  tympani  and  a  purulent  discharge  from  the  ear.  In  these  cases 
one  has  to  deal  with  a  secondary  pyogenous  infection  passing  up  the  Eusta- 
chian  tube  and  only  occasionally  with  true  diphtheria  leading  to  membrane 
formation  in  the  tympanic  cavity.  If  the  latter  does  ensue,  it  may  cause 
deep-seated  destruction  and  permanent  deafness  while  a  simple  otitis  usually 
leads  to  no  bad  results. 

DIPHTHERIA  OF  THE  LARYNX,  TRACHEA  AND  BRONCHI 

A  frequent  and  much  dreaded  localization  of  diphtheria  is  in  the  larynx 
and  the  deeper  air  passages.  The  younger  the  subject  the  more  frequently 
does  this  extension  of  the  disease  from  the  tonsils,  pharynx  or  nose  occur. 


THE  ACUTE  INFECTIOUS  DISEASES  649 

It  may  be  of  coincident  development  or  it  may  follow  the  primary  onset  in 
from  three  to  seven  days.  Sometimes  the  beginning  of  the  disease  in  the 
larynx  is  the  first  indication,  that  a  slight  coryza  or  an  insignificant  catarrhal 
or  lacunar  angina  is  of  diphtheritic  nature.  Too  much  emphasis,  however, 
cannot  be  laid  upon  the  fact,  that  laryngeal  diphtheria  is  often  primary, 
since  there  are  still  many  physicians,  who  to  the  prejudice  of  their  small 
patients  consider  the  condition  an  uncommon  one  and  think,  that  they  can 
exclude  diphtheritic  disease  in  cases  of  hoarseness  or  laryngeal  stenosis,  if 
no  membrane  is  visible  in  the  pharynx,  In  the  cold  season  during  attacks 
of  measles  and  influenza,  indeed  at  any  time  when  the  mucous  membranes 
of  the  respiratory  tract  are  injured,  primary  laryngeal  diphtheria  most  fre- 
quently appears,  while  the  pharynx  and  the  nares  may  be  and  often  remain 
free  of  the  disease.  Whether  the  laryngeal  diphtheria  in  these  cases  is 
actually  primary  as  supposed,  or  is  preceded  by  a  slightly  diphtheritic 
throat,  which  has  been  overlooked  is  not  important  for  practical  purposes. 
But  it  is  important  to  know  that  in  primary  diphtheria  of  the  larynx  cult- 
ures developed  from  the  mucus  taken  from  the  apparently  unaffected  phar- 
yngeal  wall,  will  show  diphtheria  bacilli. 

The  first  indication  of  laryngeal  diphtheria  is  hoarseness.  This  symp- 
tom gradually  becomes  more  and  more  severe  and  continuous  until  in  a  few 
days  the  voice,  increasingly  toneless  is  entirely  aphonic.  At  about  the 
same  time  and  sooner  in  young  children  than  in  older  ones,  the  inspiration 
grows  increasingly  strenuous  and  noisy  without  intervals  of  improvement 
by  day  and  without  benefit  by  treatment  as  in  pseudocroup.  The  cough 
usually  becomes  very  dry,  painful  and  lacking  in  tone. 

The  rate  at  which  the  disease  develops  varies  greatly.  A  narrowing  of 
the  glottis  occurs  within  a  very  few  days  and  this  leads  to  inspiratory  retrac- 
tion of  the  epigastrium  and  the  suprasternal  notch.  If  the  lungs  remain 
clear  and  there  is  no  rickets,  the  respirations  decrease  in  number  and  in- 
crease in  depth.  Contrasting  with  the  inspiratory  conditions  obtaining  in 
bronchitis  or  pneumonia  the  retraction  of  the  neck  above  the  clavicles  is 
added  to  that  of  the  epigastrium,  the  attachment  of  the  diaphragm  and  of 
the  larynx  being  drawn  downward  with  each  inspiration. 

According  to  the  primary  or  secondary  nature  of  the  laryngeal  infection, 
the  throat  will  appear  normal,  perhaps  slightly  injected  or  will  show  a  mem- 
brane upon  the  tonsils  or  the  pharynx.  If  a  strong  narrow  tongue  blade  is 
placed  far  back  into  the  throat  and  firm  pressure  is  applied  to  the  tongue, 
one  may  nearly  always  succeed  in  seeing  the  thickened  and  reddened 
epiglottis.  Not  infrequently  a  whitish  membrane  at  its  edge  reveals  the 
diphtheritic  nature  of  the  condition  at  once.  Rarely  is  it  possible  to  see 
the  arytenoid  cartilages,  which  are  always  markedly  swollen  and  red- 
dened. During  an  attack  of  coughing  one  can  often  see  a  tenacious  yellow 
secretion  pushing  up  through  the  glottis.  If  one  finds  no  evidence  of  diph- 
theria either  in  the  pharynx  nor  on  the  epiglottis,  the  appearance  upon 
ordinary  inspection  is  no  different  than  that  of  a  simple  laryngitis.  In  older 
children  it  is  occasionally  possible  however,  to  see  the  membrane  formation 


650  TEXT-BOOK  OF  PEDIATRICS 

on  the  false  and  true  vocal  cords  and  even  in  the  upper  end  of  the  trachea 
by  aid  of  the  laryngoscope. 

Even  in  those  cases  in  which  the  membrane  cannot  be  seen  by  any 
method  of  examination,  the  question  of  the  presence  of  laryngeal  diphthe- 
ria does  not  long  remain  in  doubt.  The  condition  becomes  gradually  but 
progressively  worse.  The  aphonia  becomes  more  and  more  complete,  the 
inspirations  more  labored  and  noisy,  but  not  so  ringing  and  audible  as  in 
pseudocroup.  The  increasingly  difficult  inspiration  soon  becomes  insuf- 
ficient to  supply  the  oxygen  requirement,  in  spite  of  the  fact,  that  all  the 
auxilliary  muscles  are  acting  and  that  the  head  is  retracted  to  assist  their 
effort.  In  young  children  the  retraction  of  the  epigastrium  until  it  almost 
touches  the  vertebral  column,  the  forcible  indrawing  of  the  suprasternal 
notch,  with  the  marked  excursions  of  the  larynx  are  definite  signs  of  a  high 
grade  laryngeal  stenosis.  The  incomplete  decarbonization  of  the  blood  in 
the  lungs  causes  cyanosis,  first  to  be  noticed  in  the  lips  and  the  finger-nails. 
The  air  hunger  makes  the  child  nervous.  Finding  no  comfortable  position, 
with  a  frightened  look  he  throws  himself  about  the  bed,  sits  up  with  head 
thrown  back  or  clings  to  the  head  of  the  bed,  striving  to  get  his  breath. 
From  hour  to  hour  the  stenosis  increases  to  the  point  of  threatened  asphyx- 
iation. In  a  coughing  fit  the  shortness  of  breath  becomes  alarming.  No 
air  can  be  forced  through  the  contracted  laryngeal  opening  with  the  most 
forcible  respiratory  efforts.  The  face  and  hands  grow  pale;  cold,  clammy 
perspiration  covers  the  body  and  the  increasing  stupor  passes  into  uncon- 
sciousness. On  a  final  strenuous  effort  the  patient  may  throw  out  the  tena- 
cious mucus  or  even  a  piece  of  membrane,  which  had  covered  the  glottis 
and  gradually  recover.  Frequently  the  child  succumbs  in  such  an  attack 
although  the  fatal  seizure  is  usually  preceded  by  a  few  lesser  ones. 

Intubation  or  tracheotomy  performed  at  the  proper  time  may  prevent 
a  fatal  outcome.  If  one  or  other  of  these  expedients  is  not  resorted  to  in 
season,  asphyxia  follows.  The  pulse  grows  smaller  and  more  frequent  and 
the  heart  finally  stops  during  an  inspiration.  The  increasing  pallor  may 
deceive  the  inexperienced  as  to  the  immediate  need  of  oxygen  supply.  The 
patient's  extreme  effort  to  get  air  gives  way  to  a  rapidly  deepening  apathy, 
which  lapses  into  somnolence  and  eventually  into  deep  coma.  In  a  few 
hours  or  within  a  day  or  two  death  ends  the  struggle.  At  autopsy  only  the 
inner  surface  of  the  larynx  may  be  found  covered  with  a  thick  membrane. 
This  may,  however,  extend  far  down  into  the  trachea  or  even  into  the 
bronchial  tree.  While  in  the  pharynx  the  membrane  is  of  more  distinctly 
diphtheritic  type,  in  the  larynx  and  trachea  it  is  often  very  superficial, 
structurally  speaking  of  a  croupous  form  and  for  this  reason  as  the  result 
either  of  effort  or  of  mechanical  interference  may  be  the  more  readily  expelled 
in  large  fragments  or  as  a  complete  mold.  The  laryngeal  stenoses  which  leave 
the  bronchi  free  are  especially  favorable  for  operative  measures.  In  these 
cases  the  results  of  tracheotomy  or  intubation  are  wonderful.  The  patient, 
who  severely  cyanotic,  was  threatened  but  a  moment  before  with  asphyxia- 
tion, regains  his  normal  color,  his  breathing  becomes  quiet  and  normal  and 
exhausted,  he  falls  into  a  restful  sleep.  To-day  it  is  possible  to  count  on 


THE  ACUTE  INFECTIOUS  DISEASES  651 

recovery  in  a  large  number  of  cases  by  the  use  of  antitoxin.  Before  the 
advent  of  the  serum  treatment,  the  disease  usually  continued  a  day  or  two 
after  the  operation  and  then  with  the  spread  of  the  process  to  the  bronchi 
of  the  first  and  second  order,  increasing  signs  of  stenosis  followed  and  soon 
death.  Now,  however,  this  fatal  spread  of  the  disease  to  the  bronchi  can 
be  prevented  by  the  employment  of  antitoxin. 

Unfortunately  cases  which  the  physician  sees  for  the  first  time  in  the 
stage  of  asphyxia,  do  not  react  so  favorably.  Tracheotomy  and  intubation 
give  but  little  relief  since  the  obstructive  membranes  have  already  extended 
to  the  bronchi.  The  continuingly  labored  breathing,  clearly  recognized 
even  before  the  operation  often  evidences  the  fact.  Examination  may  show 
no  pulmonary  signs  beyond  diminished  breathing  and  a  degree  of  acute 
emphysema  resulting  from  the  obstructed  respiration.  In  other  instances 
besides  the  formation  of  membrane  in  the  larger  bronchi,  extensive  foci  of 
broncho-pneumonia  may  coincidently  or  subsequently  appear  and  may 
have  their  part  in  aggravating  a  bad  prognosis.  Frequently  even  in  severe 
cases  the  membrane  does  not  extend  beyond  the  bifurcation  of  the  trachea 
but,  nevertheless,  foci  of  broncho-pneumonia  develop.  The  respiration  re- 
mains difficult  after  tracheotomy  or  intubation  and  the  prognosis  becomes 
more  grave. 

Further  it  is  to  be  said  that  the  course  of  diphtheritic  croup  depends 
upon  the  severity  of  the  disease  in  general,  as  well  as  upon  the  extent  of  its 
spread  to  other  parts.  As  we  have  already  suggested,  the  toxicity  and 
malignancy  of  the  disease  is  by  no  means  entirely  dependent  upon  the  area 
of  the  affected  mucous  membranes.  In  extremely  malignant  forms  of  diph- 
theria the  trachea  is  very  often  spared.  When  the  trachea  alone  is  affected 
the  mechanical  obstruction  to  the  respiration  is  the  most  prominent  symp- 
tom and  the  evidences  of  general  infection  are  sometimes  slight. 

Before  antitoxin  came  into  general  use,  cases  of  pharyngeal  diphtheria 
were  frequently  seen  in  older  children  in  which  spontaneous  recovery  oc- 
curred in  spite  of  the  fact  that  incipient  laryngeal  infection  was  indicated 
by  hoarseness  and  stenosis.  Sometimes  these  symptoms  were  due  to  a 
simple  laryngeal  catarrh  spreading  from  the  pharynx  but  at  other  times 
they  proved  to  be  true  laryngeal  or  tracheal  croup,  as  shown  by  the  ejection 
in  coughing  of  pieces  of  membrane,  or  as  demonstrated  in  fatal  cases  at 
autopsy.  At  the  present  time,  physicians  should  refuse  the  responsibility 
of  delay,  in  the  hope  of  spontaneous  recovery,  when  hoarseness  develops  in 
cases  of  diphtheria.  It  is  the  rule  in  young  children  that  the  onset  of  hoarse- 
ness is  the  signal  of  dangerous  stenosis. 

RARE  LOCALIZATIONS  OF  DIPHTHERIA 

Atypical  localizations  of  diphtheria  are  infrequent.  They  are  almost 
always  secondary  to  pharyngeal  diphtheria.  The  mucous  membrane  of  the 
cheeks  and  lips  (Fig.  165)  is  affected  more  often  than  the  tongue.  These 
departures  show  a  typical  membrane  formation.  An  injury  of  the  mucous 
surface  favors  its  appearance. 

Diphtheria  of  the  conjunctiva  is  not  so  uncommon  and  comparatively 


652 


TEXT-BOOK  OF  PEDIATRICS 


often  it  is  primary.  In  mild  cases  it  appears  as  a  delicate  croupous  exudate 
upon  the  conjunctiva  of  the  lids,  which  are  moderately  swollen  and  red- 
dened and  yield  a  purulent  secretion.  Recovery  is  often  seen  without  any 
resulting  scars.  A  true  diphtheritic  form  with  a  firmly  adherent  membrane 
on  the  contrary  is  dangerous.  The  lids  become  intensely  swollen  and  tense; 
chemosis  and  a  markedly  purulent  secretion  follow.  In  this  type  de- 
struction  of  the  cornea  often  oc- 
curs, if  treatment  with  antitoxin 
is  not  instituted  promptly. 

Diphtheria  of  the  skin  is  not 
very  uncommon  by  way  of  a  sec- 
ondary infection.  It  occurs  nota- 
bly when  the  skin  is  injured, 
particularly  on  the  upper  lip  in 
cases  of  nasal  diphtheria,  in  the 
external  auditory  meatus  follow- 
ing diphtheritic  otitis  media  and 
over  eczematous  areas.  When 
there  is  no  affection  of  the  phar- 
ynx, the  diagnosis  may  not  be 
readily  determined.  The  mem- 
brane may  be  light  and  readily 
removable  or  thick  and  firmly 
adherent  upon  a  reddened  base. 
Its  character  is  easily  determined 
by  microscopic  or  bacteriologic 
examination.  The  lesion  heals 
rapidly  if  antitoxin  treatment 
is  given. 

Diphtheria  of  the  vulva  is  un- 
common. It  is  usually  secondary 
to  pharyngeal  diphtheria  as  a  re- 
sult of  preexisting  inflammatory  conditions  of  the  labia  or  of  direct  trans- 
mission of  the  bacilli  by  means  of  the  fingers  in  the  act  of .  masturbation. 
The  inner  surfaces  of  the  vulva,  the  lesser  labia,  and  even  the  clitoris  may 
be  markedly  phlegmonous  and  covered  with  a  thick  membrane.  The  local 
infection  is  very  often  severe  and  even  gangrenous. 

PECULIARITIES  OF  DIPHTHERITIC  MEMBRANES 

The  distinctive  feature  of  the  diphtheritic  membrane  as  compared  with 
many  other  exudates  upon  the  mucosae  is  seen  in  its  tough,  elastic  quality, 
insusceptible  of  crushing,  dependent  upon  its  large  content  of  fibrin.  It 
may  often  be  torn  off  in  large  pieces  with  a  forceps. 

There  are  not  infrequently  cases  of  true  diphtheria,  however,  in  which 
these  qualities  are  not  recognizable.  A  cheesy  exudate  is  formed,  which 
on  account  of  its  low  fibrin  content,  is  soft  and  pasty  and  cannot  be  pulled 
off  in  large  lamellae.  It  resembles  the  exudate  in  scarlet  fever,  Vincent's 


FIG.  165. — Labial  diphtheria  (together  with 
pharyngeal  diphtheria). 


THE  ACUTE  INFECTIOUS  DISEASES  653 

angina  or  even  common  angina.  This  soft  exudate  is  found  especially  in 
malignant  cases,  in  gangrenous  forms  and  in  children,  who  are  seriously  ill 
with  some  such  concurrent  disease  as  tuberculosis  or  with  some  cachexia. 
On  the  other  hand,  there  are  numbers  of  non-diphtheritic  diseases  in  which 
membranes  are  formed,  which  contain  a  large  element  of  fibrins. 

THE  EFFECT  OF  DIPHTHERIA  ON  VARIOUS  ORGANS 
COMPLICATIONS  AND  SEQUELS 

A  swelling  of  the  lymph  nodes  of  the  neck  is  not  usually  so  marked  as 
it  is  in  scarlet  fever.  The  perilymphatic  tissue  is  only  affected  in  severe 
cases.  Suppuration  is  much  more  rare  than  in  scarlet  fever. 

The  Respiratory  Apparatus. — Severe  bronchitis  and  broncho-pneumo- 
nia are  frequent  sequelae  of  diphtheria  alike  in  its  pharyngeal,  laryngeal, 
tracheal  and  bronchial  forms.  By  confluence  of  numerous,  smaller  foci, 
broncho-pneumonia  may  become  very  extensive  and  particularly  in  young 
children  is  very  often  the  cause  of  death.  Diphtheria  bacilli  may  be  pres- 
ent in  pneumonic  foci,  but  streptococci  are  more  frequent  and  are  apt  to 
be  present  in  large  numbers.  Since  severely  toxic  cases,  even  when  loca- 
lized in  the  pharynx  are  especially  prone  to  develop  broncho-pneumonia  it 
may  be  supposed,  that  the  toxines  of  diphtheria  probably  predispose  the 
patient  to  this  disease. 

The  pneumonia  is  occasionally  of  a  hemorrhagic,  infarct-like  character. 
Exceptionally  it  may  proceed  to  gangrene.  Pleurisy  with  large  and  at  times 
purulent  exudate  is  rare. 

The  vascular  system  is  often  characteristically  involved.  Since  but 
seldom  are  diphtheria  bacilli  found  in  the  blood  the  circulatory  disturbance 
must  be  considered  purely  toxic.  In  malignant  cases  a  distinct  cardiac 
insufficiency  is  observed  from  the  beginning,  death,  in  consequence,  some- 
times ensuing  within  a  few  days.  The  pulse  is  found  to  be  small,  compres- 
sible and  very  frequent,  and  in  serious  cases  can  hardly  be  felt.  The  heart 
itself  often  dilates  suddenly.  Systolic  murmurs  of  muscular  origin  are  com- 
mon. In  experiments  upon  animals  profound  diphtheria  poisoning  causes 
a  marked  fall  of  blood-pressure,  but  in  the  child  the  determination  of  blood- 
pressure  is  not  of  much  significance  from  a  prognostic  viewpoint. 

Cardiac  death  is  characteristic  of  diphtheria.  It  may  occur  in  either  of 
two  ways.  The  heart  may  fail  suddenly  in  grave  cases  during  the  second 
or  third  week  of  the  disease.  Nausea,  pallor,  abdominal  pains  and  a  vary- 
ingly  irregular,  small  pulse  will  often  precede  the  heart  failure.  A  sudden 
fatality  cannot,  however,  be  foreseen  from  these  symptoms. 

The  so-called  postdiphtheritic  cardiac  death  is  especially  peculiar  to 
diphtheria.  It  may  occur  four,  six  or  even  eight  weeks  after  the  disappear- 
ance of  the  local  condition.  Here,  too,  one  has  usually  but  not  always,  to 
deal  with  severe  forms  of  the  disease,  the  sufferers  from  which  do  not  com- 
pletely recover  but  remain  pallid,  weak,  without  appetite,  and  often  have 
albuminuria  for  a  long  while.  The  pulse  remains  persistently  small,  very 
rapid  and  irregular.  Forms  in  which  a  slowing  of  the  pulse-rate  occurs 
from  time  to  time  are  particularly  dangerous.  In  these  cases  the  heart  is 


654  TEXT-BOOK  OF  PEDIATRICS 

usually  dilated  and  systolic  muscular  murmurs  are  audible.  The  entire 
picture  is  one  of  marasmus,  resulting  from  a  severe  general  intoxication, 
which  doubtless  affects  primarily  the  heart.  The  least  exertion  increases 
the  pulse-rate  very  markedly  and  may  cause  alarming  weakness.  From 
time  to  time  attacks  of  exhaustion  with  sudden  pallor,  shortness  of  breath, 
vomiting  and  abdominal  pain  occur  without  any  external  cause.  The  slow- 
ing of  the  pulse  indicates  special  danger.  The  heart  is  able  to  recover  after 
weeks  of  marasmus  with  alarming  attacks  occurring  at  intervals.  Often  it 
does  not  recover  its  normal  power  for  months.  This  is  most  apparent  when 
intercurrent  infections  are  present.  Sometimes  after  all  danger  seems 
passed,  sudden  cardiac  death  may  result  and  even  so  late  as  six  or  eight 
weeks  after  the  onset  of  the  disease.  This  acute  heart  failure  is  due  in  part 
to  myocarditis  and  in  part  to  degeneration  of  the  vagus.  In  some  instances 
embolism  of  the  large  cerebral  arteries  develops.  The  frequent  circulatory 
weakness  appearing  at  the  height  of  the  disease  depends  largely  upon  vaso- 
motor  disturbances. 

The  blood  does  not  show  any  constant  or  typical  changes.  Besides  a 
decrease  of  the  red  blood-cells  the  appearance  of  myelocytes  is  noted  in 
severe  forms  of  the  disease.  Leucocytosis  is  of  frequent  occurrence. 

The  Digestive  Apparatus. — In  grave  cases  the  appetite  may  be  entirely 
lost.  The  tongue  is  covered  with  sordes.  Obstinate  anorexia  is  always  a 
bad  sign.  Vomiting  occurs  frequently.  Serious  diarrhoea  often  appears,  an- 
other bad  indication. 

The  Kidneys. — In  many  cases  albuminuria  appears  as  early  as  the 
second  or  third  day.  The  urine  contains  large  quantities  of  sediment  and 
casts.  The  latter  may  be  present  without  albuminuria.  An  advanced 
degree  of  nephritis  with  epithelial  casts  is  infrequent.  The  protein  content 
usually  remains  below  0.3  per  cent.  The  convoluted  tubules  of  the  cortex 
are  most  seriously  involved.  The  severity  of  the  nephritis  is  a  fair  indicator 
of  the  measure  of  the  general  intoxication.  The  renal  disturbance  usually 
abates  as  the  patient  recovers  from  diphtheria.  Its  persistence  in  the  form 
of  a  chronic  nephritis  is  extremely  rare.  The  urine  hardly  ever  contains 
blood.  In  contradistinction  to  the  nephritis  of  scarlet  fever,  that  of  diph- 
theria hardly  ever  results  in  edema  and  even  more  rarely  in  uremia. 

The  Nervous  System. — The  toxins  of  diphtheria  seem  to  have  a  special 
affinity  for  the  nervous  system  as  they  do  for  the  heart.  This  reaction 
manifests  itself  in  the  development  of  pareses  and  paralyses. 

Paralysis  of  the  soft  palate  is  the  most  common  form  following  pharyn- 
geal  diphtheria.  The  so-called  early  paralysis  should  not  be  confused  with 
it,  since  it  makes  its  appearance  during  the  first  few  days  of  the  disease, 
while  the  membranes  are  still  present  and  depends  upon  the  inflammatory 
infiltration  of  the  soft  palate.  A  true  paralysis  does  not  as  a  rule  develop 
before  the  second  week  and  from  that  date  on  to  the  fourth  week,  that  is, 
not  until  after  the  membranes  have  disappeared.  In  this  condition  the 
voice  takes  on  a  nasal  quality  termed  rhinolalia  aperta.  The  attempt  to 
swallow  thin  fluids  causes  coughing  and  a  part  of  the  food  is  regurgitated 
through  the  nose.  Inspection  shows  the  soft  palate  and  the  uvula  hanging 


THE  ACUTE  INFECTIOUS  DISEASES 


655 


flaccid  and  inactive  alike  in  phonation  and  respiration.  Sometimes  only 
one  side  is  paralyzed  and  usually  in  those  cases  no  membrane  has  been 
formed  upon  the  normal  side.  Frequently  both  reflex  action  and  sensation 
are  lost  in  the  paralyzed  part.  Recovery  gradually  occurs  in  from  two  to 
four  weeks.  Often  the  musculature  of  the  pharynx  is  also  paretic,  swallow- 
ing, as  a  result  being  very  difficult  or  altogether  impossible. 

Paralysis  of  accommodation  comes  next  in  order  of  frequency  to  that  of 
the  soft  palate.  In  young  children  this  event  is  often  overlooked  and  it  is 
noticeable  only  that  fixation  upon  a  finger  approaching  the  eyes  is  not  as 
rapid  as  normally.  School  children  may  complain  of  their  inability  to 
write  and  more  often  to  read.  Paralyses  of  the  external  ocular  muscles  and 
especially  of  one  or  both  abducens  are  quite  common.  These  result  some- 
times in  convergent  paralytic  strabis- 
mus and  diplopia.  Diminution  or 
suppression  of  the  patellar  reflex  is 
usually  associated  with  these  paralyses. 
This  change,  whether  associated  with 
or  independent  of  these  paralyses,  may 
persist  for  some  weeks. 

Besides  these  more  frequently  af- 
fected muscles  and  indeed  much  more 
rarely,  other  muscle  groups  may  be  in- 
volved in  diphtheritic  paralysis.  Actual 
paralysis  of  the  lower  extremities  is 
uncommon  but  diphtheria  often  causes 
muscular  weakness  or  ataxia.  Not  so 
unusual  is  the  involvement  of  the  neck 
muscles,  but  extension  to  the  muscles 
of  the  face,  larynx  and  back  is  excep- 
tional. Very  rarely  almost  all  the  mus- 
cles of  the  body  may  become  paretic. 
Paralysis  of  the  diaphragm  and  other 
respiratory  muscles  is  of  course  dangerous.  Seldom  are  pronounced  dis- 
turbances of  sensation  in  the  form  of  parsesthesia,  dimunition  of  the  pain 
sense,  etc.,  to  be  demonstrated.  The  nerve  roots  are  not  usually  painful 
on  pressure.  In  cases  of  marked  paralysis,  incontinence  of  the  urine  and 
feces  are  often  observed.  Electrical  tests  may  show  partial  reactions  of 
degeneration.  The  pathologic  basis  of  diphtheritic  paralysis  is  a  degener- 
ation of  the  peripheral  nerves.  Cases  in  which  a  membrane  forms  on  only 
one  side  and  in  which  the  same  side  of  the  soft  palate  is  paralyzed,  or  in 
which  after  diphtheria  of  the  skin,  its  underlying  muscles  are  paralyzed, 
seem  to  indicate  that  the  diphtheritic  toxin  travels  from  the  affected  areas 
to  the  central  nervous  system  along  the  nerve  paths.  Unless  the  disease 
proves  fatal  nearly  all  of  these  paralyses  recover  without  leaving  any 
permanent  injury. 

The  Skin. — In  the  early  stages  of  diphtheria  although  rarely  before  the 
third  day,  an  erythema  sometimes  makes  its  appearance.    It  may  be  diffuse 


^HBI^HB^^L  i 

FIG.  166. — Postdiphtheritic  paralysis  of  the 
abducens  and  paralysis  of  the  facial.  Seven- 
year-old  girl. 


656     .  TEXT-BOOK  OF  PEDIATRICS 

but  it  is  usually  a  narrowly  localized  matter.  Its  character  is  generally 
that  of  a  rubeolar,  scarlatinal  or  urticarial  type.  Such  an  exanthem  is 
transitory  and  usually  disappears  within  a  day  or  two.  As  a  rule  it  may  be 
readily  distinguished  from  a  serum  exanthem  by  the  date  of  its  appearance. 
Very  malignant  and  rapidly  fatal  cases  show  small  discrete  hemorrhages  in 
the  skin  of  various  parts  of  the  body.  These  are  sometimes  associated  with 
epistaxis  and  with  bleeding  of  the  pharyngeal  surfaces  affected  by  the  disease. 

THE  DIAGNOSIS  OF  DIPHTHERIA 

The  diagnosis  is  seldom  difficult  where  one  has  to  deal  with  a  distinct 
membrane  of  the  usual  physical  qualities,  situated  on  the  tonsils  or  in  the 
pharynx.  In  all  doubtful  cases  one  must  fall  back  upon  the  bacteriologic 
diagnosis.  Nevertheless,  an  experienced  observer  will  make  a  correct  diag- 
nosis in  the  great  majority  of  cases  upon  the  clinical  findings  alone.  In 
questionable  cases  patient  observation  will  often  clear  up  the  problem, 
since  the  formation  of  a  membrane  together  with  other  symptoms  as  in- 
creasing laryngeal  stenosis  become  more  apparent. 

DIFFERENTIAL  DIAGNOSIS 

Catarrhal  angina  can  be  distinguished  from  diphtheria  only  by  bacterio- 
logic examination.  Tonsillar  or  pharyngeal  diphtheria  always  has  a  ca'tar- 
rhal  inflammatory  prodromal  stage,  which  is  followed  in  a  day  or  two  by 
membrane  formation. 

Diphtheria  quite  often  begins  with  lacunar  exudates  and  may  so  con- 
tinue throughout  its  course.  Usually,  however,  the  small  islands  of  exuda- 
tion fuse  into  a  single  membrane  in  a  day  or  two.  In  simple  lacunar 
angina  the  exudates  in  the  individual  crypts  may  become  confluent  and 
cover  the  entire  tonsil  or  a  large  part  of  it.  Usually,  the  differentiation  is 
not  difficult.  In  lacunar  angina,  which  runs  its  course  without  fever  more 
rarely  than  does  diphtheria,  the  content  of  the  crypts  is  yellowish,  purulent 
and  soft ;  it  is  easily  removed  with  an  applicator  armed  with  dry  cotton ;  it 
has  usually  a  bad  odor.  It  is  readily  broken  up  into  a  soft  paste  when 
rubbed  between  cover  glasses.  The  diphtheritic  exudate  of  the  lacunae  is 
more  whitish  and  is  adherent.  It  cannot  be  removed  with  the  applicator, 
but  if  torn  off  with  forceps  it  proves  to  be  a  firm  and  elastic  membrane. 

Greater  difficulty  is  experienced  in  the  differentiation  of  scarlatinal 
angina  and  Vincent 's  angina.  In  scarlet  fever  the  exudate  in  the  pharynx 
often  presents,  at  the  outset,  the  same  characteristics  of  a  tough  fibrinous 
membrane,  so  that  at  this  time,  if  the  exanthem  is  wanting,  the  clinical 
differentiation  is  often  impossible.  The  reddening  of  the  throat,  however, 
is  usually  much  more  intense  in  scarlet  fever  than  in  diphtheria.  Later  the 
appearance  of  the  rash,  the  strawberry  tongue,  etc.,  aid  in  establishing  a 
correct  diagnosis.  The  exudate  in  scarlet  fever  usually  contains  less  fibrin, 
is  more  deeply  imbedded  in  the  mucous  membrane  and  more  readily  results 
in  ulcer  formation.  A  favorite  location  of  the  scarlet  fever  necrosis,  from 
which  the  diphtheritic  membrane  is  usually  absent  is  on  the  anterior  pillars 
of  the  fauces  directly  in  front  of  the  tonsils. 


THE  ACUTE  INFECTIOUS  DISEASES  657 

Vincent's  or  ulcerative  angina  resembles  pharyngeal  diphtheria  so 
closely,  that  it  is  usually  confused  with  it  unless  a  bacteriologic  diagnosis 
is  made  (see  page  251).  This  discovers  diphtheria  bacilli  in  the  one  case 
and  spirochaetes  with  fusiform  bacilli  in  the  other.  In  the  ulcerative  angina 
the  exudate  frequently  occurs  upon  one  tonsil  alone.  It  is  soft  and  adherent 
but  contains  little  fibrin.  It  has  a  characteristic  foul  odor  and  after  recovery 
commonly  leaves  a  distinct  ulcer.  The  fever  and  the  general  health  dis- 
turbances are  slight. 

With  a  little  care,  unusual  forms  of  thrush,  aphthous,  herpetic,  or  luetic 
angina  and  Bednar's  aphthae  covered  with  membrane,  hardly  need  to  be 
confused  with  diphtheria.  Various  bacteria,  as  pneumococci,  streptococci, 
etc.,  occasionally  cause  membranous  exudates  of  the  pharynx,  the  nature 
of  which  can  be  determired  by  bacteriologic  examination  alone.  Severe 
parenchymatous  tonsillitis  sometimes  develops  a  veil-like  membrane  resem- 
bling that  which  is  seen  in  the  early  stages  of  diphtheria. 

DIFFERENTIAL  DIAGNOSIS  OF  AFFECTIONS  OF  THE  LARYNX 

When  increasing  hoarseness  develops  coincidently  with  pharyngeal  or 
nasal  diphtheria,  or  appears  a  few  days  later,  the  diagnosis  of  laryngeal 
diphtheria  may  be  definitely  made.  When,  however,  there  is  no  other 
evidence  of  diphtheria,  a  prompt  diagnosis  may  be  difficult.  With  a  rapidly 
increasing  hoarseness,  leading  to  aphonia  and  to  more  and  more  marked 
stenosis,  with  attacks  of  suffocation,  diphtheria  is  always  to  be  suspected. 
A  streak  culture  in  agar  of  the  mucous  from  the  pharynx  or  the  larynx  will 
usually  show  the  diphtheria  bacillus. 

Pseudocroup  hardly  ever  causes  any  serious  doubt.  This  condition 
commonly  develops  suddenly  as  the  child  is  dropping  off  to  sleep  and  in 
most  cases  without  any  premonitory  signs.  It  leads  to  a  degree  of  hoarse- 
ness and  to  intense,  but  rapidly  subsiding  stenosis  of  the  larynx.  The 
cough,  of  a  ringing,  strident  quality,  and  the  inspiratory  retraction  are  very 
intense.  The  speaking  voice  is  much  less  affected.  The  inflammation  of 
the  larynx  below  the  glottis  which  occasions  some  difficulty  in  the  introduc- 
tion of  a  tube  beyond  the  vocal  chords,  closely  resembles  true  croup. 

The  retropharyngeal  abscess  of  young  subjects  causes  hoarseness  when- 
ever the  inflammation  of  the  mucous  membrane  spreads  to  the  larynx. 
This,  together  with  the  existing  stenosis  of  the  pharynx,  may  simulate 
croup.  The  true  condition  is  revealed  by  careful  inspection  or  more  readily 
still  by  palpation. 

Severe  acute  laryngitis,  often  occurring  in  the  course  of  acute  infectious 
disorders  of  the  upper  air  passages,  as  influenza,  la  grippe  and,  particu- 
larly, measles,  offers  special  difficulties.  In  measles  the  symptoms  are  often 
absolutely  identical  with  those  of  diphtheritic  croup  (see  page  609).  To 
this  fact  is  added  the  difficulty  that,  combined  with  measles,  true  diphtheria 
usually  affects  the  larynx  and  the  trachea. 

Laryngeal  and  tracheal  stenosis  caused  by  papilloma,  goitre,  hyper- 
plasia  of  the  thymus,  tuberculosis  of  the  bronchial  nodes,  etc.,  may  usually 
42 


658  TEXT-BOOK  OF  PEDIATRICS 

be  excluded  very  readily  by  a  careful  study  of  the  history,  with  painstaking 
observation  of  the  case. 

Hoarseness  and  laryngeal  stenosis  are  not  uncommon  in  young  children, 
as  results  of  the  presence  of  foreign  bodies,  which  while  located  in  the  larynx 
cause  attacks  of  suffocation  and,  later,  wedged  in  a  bronchus,  lead  to  a  mis- 
taken diagnosis  of  croup.  An  inadequate  history  of  an  attack  of  suffoca- 
tion and  hoarseness,  coming  on  suddenly  during  a  meal,  or  while  at  play, 
always  justifies  the  suspicion  of  a  foreign  body,  which  should  dictate  a 
Roentgen  examination. 

Several  instances  have  been  observed  in  which  tracheotomy  or  intuba- 
tion has  been  performed  for  the  relief  of  an  intense  dyspnoea,  with  inspira- 
tory  retraction  and  cyanosis,  but  without  marked  hoarseness,  in  which  the 
operation  has  given  no  relief  nor  has  it  prevented  a  fatal  termination. 
Autopsy  has  revealed  neither  diphtheria  nor  any  other  essential  condition 
of  disease  of  the  respiratory  organs.  Simply  a  status  lymphaticus  was 
present,  which  was  necessarily  held  responsible  for  the  severity  of  the  dis- 
turbance and  its  result. 

The  postdiphtheritic  paralyses  are  so  generally  characteristic,  that 
they  enable  one  to  make  a  diagnosis  of  previous  diphtheria,  even  in  the 
absence  of  history  or  with  a  record  of  an  attack  so  slight  that  its  nature 
was  overlooked.  Their  most  significant  sign  is  a  paralysis  of  the  soft  palate. 

Bacteriologic  Diagnosis. — One  cannot  sufficiently  emphasize  the  fact, 
that  where  there  is  any  doubt  whatever  concerning  the  diagnosis,  material 
removed  from  the  throat  must  be  subjected  to  bacteriologic  examination. 
Usually  culture  tubes  can  be  sent  to  municipal  or  state  institutions  for 
diagnosis.  In  the  course  of  this  discussion  we  have  called  attention  to  the 
fact,  that  even  thick  elastic  membranes  are  not  always  diphtheritic  and 
reversely  that  diphtheria  often  runs  its  course  without  the  formation  of  a 
membrane  or  at  least  in  the  absence  of  any  characteristic  deposit. 

A  small  piece  of  the  exudate  to  be  examined  is  removed  with  the  forceps 
or  other  instrument;  it  is  washed  in  pure  water  and  crushed  as  fully  as  pos- 
sible between  two  microscopic  slides.  As  an  alternative,  it  may  be  sufficient 
to  wipe  off  the  membrane  with  a  cotton-covered  applicator.  If  there  is  no 
membrane,  a  little  mucus  removed  from  the  suspected  mucous  membrane 
either  on  the  pharyngeal  wall  or  in  the  suspected  larynx,  is  spread  upon  a 
slide.  This  is  dried  and  stained  with  Loeffler's  methylene  blue.  If  diph- 
theria is  present  there  are  found,  beside  numerous  cellular  elements,  debris 
and  often  threads  of  fibrin,  various  kinds  of  bacteria  and  among  them  large 
numbers  of  diphtheria  bacilli.  These  may  even  predominate.  They  are 
recognized  as  thick,  almost  club-shaped  rods,  which  stain  irregularly  and 
are  characteristically  found  in  nests  or  clumps  hang  at  sharp  angles  to  each 
other  (see  Fig.  167).  This  simple  technic  which  any  physician  can  carry1 
out  with  a  little  practice  is  usually  satisfactory,  so  far  as  the  examination 
of  the  membrane,  is  concerned.  It  must  be  borne  in  mind,  however,  that 
even  in  true  diphtheria,  and  especially  with  old  membranes,  it  is  often 
impossible  to  find  the  bacillus.  In  that  event  and  particularly  if  only  mucus 
has  been  removed  from  the  throat,  it  is  necessary  to  make  a  culture  upon 
Loeffier's  blood  serum,  on  which  the  organism  grows  very  freely.  For  fur- 


THE  ACUTE  INFECTIOUS  DISEASES 


659 


ther  and  absolute  identification,  an  inoculation  test  upon  animals  may  be 
made.  This  gives  the  most  definite  differentiation  between  the  true  bacillus 
and  the  non-virulent  forms  of  pseudodiphtheritic  bacilli.  This  identifica- 
tion cannot  be  made  absolutely  with  Neisser  's  double  stain  of  fresh  cultures 
for  polar  bodies,  since  this  polar  nucleation  is  sometimes  absent  in  the  case 
of  true  diphtheria  bacilli  and  is  definitely  lacking  in  the  pseudo-forms. 
For  a  more  complete  description  of  the  bacteriologic  diagnosis  of  diphtheria, 
the  reader  is  referred  to  standard  text-books  of  bacteriology. 

The  prognosis  of  diphtheria  depends  to  a  great  degree  upon  the  char- 
acter of  the  disease.  The  type  is  generally  more  severe  during  epidemics  than 


FIG.  167. — Diphtheria  bacilli.     Smear  from  exudate  on  tonsil. 
Leitz    f%,  ocular  3.     Tube  length  16. 

it  is  in  sporadic  cases.  The  younger  the  patient  the  less  favorable  is  the 
prognosis,  so  that  infants  hardly  ever  escape  unless  under  treatment  with 
antitoxin.  The  disease  is  also  especially  fatal  among  tuberculous  and 
cachectic  subjects.  The  spread  of  the  diphtheritic  process  to  the  nose  or 
the  larynx  always  reduces  the  chances  of  recovery.  Localized  forms,  con- 
fined to  the  tonsils,  have  a  generally  favorable  prognosis.  An  intense 
inflammation  in  the  throat,  a  gangrenous  type  of  infection,  the  unusual 
enlargement  of  the  lymph  nodes,  an  extensive  infiltration  of  the  perilym- 
phatic  tissue,  a  severe  general  toxicity,  cardiac  weakness,  etc.,  are  all  indic- 
ative of  a  particularly  malignant  form  of  the  disease.  Even  with  a  seemingly 
satisfactory  course  and  after  recovery  from  the  purely  local  manifestations, 
the  prognosis  must  always  be  made  with  reserve,  since  diphtheritic  paraly- 
ses or  serious  myocardial  changes  causing  sudden  cardiac  death  may  fol- 
low later. 


660  TEXT-BOOK  OF  PEDIATRICS 

At  the  present  time,  the  prognosis  depends  chiefly  upon  the  early  admin- 
istration in  sufficient  quantities  of  antitoxin.  The  discovery  of  antitoxin 
by  Behring  may  be  said  to  be  the  greatest  triumph  and  the  richest  blessing 
of  scientific  therapeutics,  as  a  result  of  which  diphtheria  has  largely  lost  its 
terrors.  There  is  hardly  another  serious  disease  upon  which  the  physician 
can  look  with  so  great  certainty  and  assurance  as  he  can  upon  diphtheria 
to-day.  Early  treatment  is,  of  course,  essential.  Cases  that  receive  suf- 
ficient doses  of  antitoxin  on  the  first  or  second  day  of  the  disease  recover 
almost  without  exception,  as  is  shown  in  the  tabulated  statement  on  page 
663.  With  every  day,  yes,  with  every  hour  that  the  injection  of  antitoxin 
is  delayed  the  chances  of  the  child  are  diminished.  The  enthusiastic  sup- 
porters of  this  therapy  must  admit,  however,  that  there  are  occasional  cases 
in  which  the  individual  predisposition  is  extraordinarily  great  and  which 
cannot  be  saved  even  though  antitoxin  is  given  the  first  day.  These  excep- 
tions do  not  alter  the  fact  that  early  injection  will  cure  almost  all  cases— a 
fact  which  is  supported  by  the  history  of  recent  epidemics  in  Berlin  and 
Hamburg.  That  there  are  such  exceptions  makes  the  duty  to  employ  the 
remedy  early  the  more  imperative.  The  failure  to  use  it  at  the  proper  time 
is  an  inexcusable  and  often  fatal  error. 

The  prognosis  of  croup  during  measles,  in  which  the  membrane  forma- 
tion rapidly  spreads  to  the  smaller  bronchi,  is  relatively  bad  and  demands 
early  and  energetic  serum  treatment. 

Prophylaxis. — Prophylaxis  requires  the  isolation  of  the  patient,  who 
must  be  sent  to  a  contagious  hospital  if  the  isolation  cannot  be  achieved 
successfully  at  home.  After  the  recovery  or  removal  of  the  patient  the 
room  must  be  disinfected.  The  other  members  of  the  family  should  be 
carefully  watched  and  throat  cultures  taken.  If  necessary,  a  prophylactic 
injection  of  antitoxin  may  be  given. 

The  avoidance  of  the  disease  is  greatly  favored  by  proper  hygiene,  by 
frequent  gargling  with  cold  water,  to  the  glassful  of  which  five  drops  of 
tincture  of  myrrh  may  be  added,  and  by  cleanliness  of  person  and  dwelling. 
The  patient  should  not  be  permitted  contact  with  other  members  of  the 
family  for  fourteen  days  after  the  disappearance  of  the  local  symptoms. 
If  diphtheria  bacilli  are  still  found  on  the  mucous  membrane,  isolation 
should  be  continued  until  they  have  entirely  disappeared.  Even  a  longer 
time  should  elapse  before  the  patient  is  allowed  to  return  to  school.  If 
several  cases  of  diphtheria  appear  in  a  school  or  in  a  children 's  hospital  it  is 
usually  possible  to  weed  out  the  healthy  bacillus  carriers  by  systematic 
bacteriologic  examination  of  all  the  inmates.  In  infants  special  attention 
should  be  paid  to  the  nasal  discharges.  By  isolating  carriers  the  spread  of 
infection  is  often  successfully  checked. 

Treatment. — The  serum  therapy,  the  basic  principles  of  which  are  gener- 
ally known,  is  the  most  important  method  of  treatment  to  be  employed  in 
this  disease.  The  danger  from  diphtheria  is  largely  due  to  the  toxin  pro- 
duced by  the  bacilli,  although  the  organisms  themselves  reach  the  blood 
stream  or  the  viscera  in  very  small  numbers.  Spontaneous  recovery  occurs 
as  the  result  of  the  action  of  certain  protective  substances  present  in  the 


THE  ACUTE  INFECTIOUS  DISEASES 


661 


body  and  more  especially  by  the  action  of  specific  antibodies,  the  diphtheria 
antitoxins  which  the  body  forms  to  combat  the  circulating  diphtheritic 
toxin.  If  the  organism  proves  able  to  form  sufficient  antitoxin  at  the  right 
time  to  achieve  an  active  immunity  recovery  takes  place.  Otherwise  the 
disease  is  fatal.  This  antitoxin,  however,  does  not  affect  the  bacteria,  and 
therefore  convalescents  and  those  who  have  fully  recovered  from  the  disease 
may  harbor  virulent  diphtheria  bacilli  for  a  long  time.  The  significance  of 
the  serum  therapy  lies  in  the  fact  that  it  supplies  an  artificial  antitoxin  to 
aid  the  organism  in  combating  the  disease  toxin.  By  repeatedly  injecting 
the  horse  with  the  germ-free  filtrate  of  a  virulent  culture  of  diphtheria 
bacilli,  the  blood-  serum  of  the  animal  acquires  in  time  a  high  degree  of  im- 
munity, that  is,  it  contains  a  large  amount  of  diphtheria  antitoxin.  The 
term  immunity  unit  (I.  U.),  has  been  generally  adopted  to  signify  that 
amount  of  antitoxin-containing  serum  which  will  completely  neutralize  the 
effects  of  100  lethal  doses  of  toxin  in  a  guinea  pig  weighing  250  grams. 
We  speak  of  simple  antitoxic  serum  when  this  unit  is  contained  in  1  c.c. 
of  serum.  In  late  years  the  sera  in  use  are  usually  400  to  500  times  as 
strong  as  the  simple  serum,  1  c.c.  containing  400  to  500  I.  U. 

Dose. — For  prophylactic  purposes,  500  I.  U.,  or,  according  to  Schick, 
50  I.  U.  per  kilo  of  body- weight,  are  sufficient  to  give  a  passive  immunity 
lasting  for  two  to  three  weeks.  In  the  treatment  of  the  disease  in  its  several 
forms  the  following  doses  may  be  given  by  intramuscular  injection:  For 
localized  pharyngeal  diphtheria,  1500  to  2000  I.  U.;  for  nasal  or  laryngeal 
diphtheria,  3000  to  4000  I.  U.;  for  malignant  diphtheria,  5000  I.  U.  These 
doses  may  be  given  irrespective  of  the  age  of  the  patient.  If  no  results  are 
observed  within  twenty-four  hours,  the  dose  is  to  be  repeated  once  more. 

American  authors  are  definitely  of  the  opinion  that  the  best  results  are 
obtained  in  the  treatment  of  diphtheria  by  larger  doses  of  antitoxin.  Park 
recommends  the  following  dosage: 


Mild  cases. 
Units 

Early  moderate 
cases. 

Units 

Late  moderate 
and  early  severe* 

Units 

Severe  and 
malignant* 

Units 

Infants  (10-30  pounds  in  weight 
under  2  vrs.)  

2000-3000 

3000-5000 

5000-10000 

7500-10000 

Children  (30-90  pounds  in 
weight  under  15  yrs.)  

3000-4000 

4000-10000 

10000-15000 

10000-20000 

Adults  (90  pounds  or  over  in 
weight.)  

3000-4000 

5000-10000 

10000-20000 

20000-50000 

Method  of  administration 
advised  

Intramus- 

Intramus- 

Intravenous 

cular. 

cular 

*When  given  intravenously,  the  smaller  amounts  stated.  When  children  or  adults 
have  been  exposed  to  diphtheria  they  may  be  protected  from  the  disease  by  the  subcu- 
taneous administration  of  from  500-1000  units,  a  smaller  dose  being  sufficient  for 
infants  and  young  children.  The  protection  does  not  last  longer  than  from  2-4  weeks. 


662 


TEXT-BOOK  OF  PEDIATRICS 


Recently,  Schick  determined  by  experiment  that  the  maximal  results 
of  antitoxin  are  obtained  with  500  I.  U.  per  kilo  of  body-weight.  In  light 
cases,  he  recommends  that  100  I.  U.  per  kilo  be  injected,  less  than  this 
having  no  action;  in  severer  cases,  proportionately  to  the  seriousness  of  the 
attack,  he  increases  the  dose  up  to  500  I.  U.  per  kilo. 

A  satisfactory  effect  within  twenty-four  hours,  is  announced  by  a  fall  of 
temperature  (Fig.  168) ;  a  decrease  of  the  pulse-rate,  and  an  improvement 
in  the  general  condition.  During  this  period  the  membrane  formation 
ceases  or  shows  but  very  slight  extension  in  those  areas  in  which  necrosis 
had  developed  before  the  injection  was  given.  Similarly,  laryngeal  stenosis 
may  increase  during  the  first  twenty-four  hours  after  the  injection,  subse- 
quent to  which  decided  improvement  is  to  be  expected  if  the  treatment  is 
successful.  The  favorable  influence  of  the  serum  is  first  manifest  in  a 


FIG.  168. — Pharyngeal  diphtheria  in  six-year-old  girl.    Rapid  fall  of  temperature 
after  injection  of  antitoxin. 

distinct  red  area  of  demarcation  around  the  membrane,  which  soon  curls 
up  at  the  edges,  becomes  loose  and  soft  and  in  from  two  to  four  days  is 
entirely  loosened  and  cast  off.  If  no  such  distinct  results  are  visible  within 
twenty-four  hours  a  second  injection  should  be  given. 

In  the  administration  of  antitoxin,  absolute  asepsis  must  be  observed. 
An  ordinary  5  c.c.  syringe  may  be  used.  The  site  of  the  nrection  may  be 
covered  with  cotton  and  collodion. 

Since  resorption  from  the  muscle  is  much  more  rapid  than  from  the 
subcutaneous  cellular  tissue,  the  hypodermatic  method  may  be  entirely 
discarded  and  all  injections  be  given  intramuscularly.  The  outer  side  of 
the  thigh  or  the  gluteal  region  is  generally  preferred.  The  intramuscular 
is  less  painful  than  the  subcutaneous  injection.  The  weight  of  experience 
in  animal  experiments  shows  that  intravenous  injection  acts  much  more 
rapidly  than  either,  and  may  often  save  life  where  the  subcutaneous  or 
even  the  intramuscular  method  would  be  in  vain.  For  this  reason  the 
intravenous  use  of  the  serum  has  come  into  more  and  more  frequent  practice 


THE  ACUTE  INFECTIOUS  DISEASES 


663 


during  the  last  few  years.  According  to  all  reports  supported  by  the 
writer 's  experiences,  its  results  are  very  favorable  and  unattended  by  special 
danger  of  anaphylaxis.  In  this  clinic,  however,  the  intramuscular  injec- 
tion is  the  routine  practice;  the  intravenous  method  being  reserved  for 
severe  cases  when  the  veins  of  the  arm  can  be  used  without  special  prepara- 
tion. Even  in  these  cases  the  latter  method  is  not  employed  if  the  patient 
has  received  a  previous  injection  within  a  few  months. 

The  mode  of  operation  of  the  serum  is  not  entirely  clear.  Its  action  is 
probably,  in  the  main,  one  of  neutralization,  rendering  the  circulatory 
toxins  inactive.  When  the  toxin  has  already  become  anchored  to  the  cell 
substance  as,  for  instance,  in  the  heart  or  the  nerve  tissue,  the  use  of  anti- 
toxin will  accomplish  little  or  nothing.  It  follows  that  the  objections  of 
dissenters  to  the  use  of  antitoxin,  who  deny  its  action  because  it  does  not 
prevent  myocarditis  or  paralysis,  are  not  tenable,  since  these  injuries  have 
been  suffered  before  the  introduction  of  the  serum.  Even  the  alleged 
increase  of  the  diphtheritic  paralyses,  which  is  claimed  to  have  occurred 
since  the  introduction  of  antitoxin,  does  not  sustain  these  views,  since  many 
severe  cases  which  formerly  would  have  proved  rapidly  fatal  now  survive 
and  develop  sequelae.  With  many  other  authors,  I  have  gained  the  impres- 
sion that  paralyses  are  less  common  where  early  injection  is  had  than  formerly. 

The  actual  value  of  the  serum  therapy  is  proved  conclusively  by  the 
reduced  fatality  of  the  disease  as  compared  with  that  of  former  years. 

According  to  statistics  gathered  by  Deycke  in  78,028  cases,  the  mortality 
after  serum  injection  is  shown  by  the  following  figures: 


Date  of  injection 

1st  day 
Per  cent. 

2nd  day 
Per  cent. 

3rd  day 
Per  cent. 

4th  day 
Per  cent. 

5th  day 
Per  cent. 

6th  day 
Per  cent. 

After  6th  Day 
Per   cent. 

Deaths  

4.3 

7.6 

14.7 

19.7 

31.6 

31.3 

31.6 

Still  more  convincing  is  the  fact  that  under  serum  treatment  about  two- 
thirds  of  the  operative  cases  recover,  while  without  it  only  one-third  escape. 
Further  the  canula  and  the  tube  need  not  be  left  in  place  as  long  as  they 
were  before  antitoxin  was  used.  Another  fact  which  bears  upon  the  benefit 
derived  from  the  antitoxin  treatment  of  diphtheria  is  that  with  its  use  the 
disease  hardly  ever  spreads  to  the  larynx  and  the  trachea — an  extension 
which  was  formerly  of  common  occurrence.  Again  it  is  noted,  in  distinct 
contrast  to  earlier  experiences,  that  with  antitoxin  treatment  threatened 
laryngeal  stenosis  almost  always  abates  without  necessitating  operative 
interference.  The  opponents  of  serum  therapy,  who  are  not  nearly  so 
numerous  as  they  were  a  few  years  ago,  have  but  one  argument  left — the 
danger  of  injuries  to  the  child  from  the  injection.  These  injuries,  however, 
are  so  uncommon  and  usually  so  insignificant  that  they  cannot  be  considered 
in  face  of  the  wonderful  benefits  the  method  has  conferred.  Nevertheless, 
serum  disease  is  to  be  recognized. 

Serum  Disease. — If  the  serum  of  one  animal  is  introduced,  either  sub- 
cutaneously  or  intravenously,  into  another  animal  of  a  different  species 


664 


TEXT-BOOK  OF  PEDIATRICS 


pathologic  changes  often  occur.  For  human  beings  this  fact  has  taken  on 
a  special  significance  on  account  of  the  frequency  of  the  use  of  antidiph- 
theritic  serum.  Such  changes  may  appear,  similarly,  when  antitetanic  or 
antimeningococcic  serum,  etc.,  are  used,  since  they,  too,  represent  sera 


FIG.  169. — Serum  exanthem,  resembling  measles  and  erythema 
appearing  ten  days  after  injection  in  the  neighborhood  of 
the  injection. 

from  animals  of  different  species  and  do  not  merly  consist  of  the  specific 
antibodies  derived  from  them. 

Serum  disease  has  been  exhaustively  studied  by  von  Pirquet  and  Schick. 
After  the  first  injection  with  antidiphtheritic  serum,  that  is,  of  horse  serum, 
containing  antitoxin,  a  painful  inflammation  develops  within  a  few  days  in 
the  lymph  nodes  draining  the  region  tributary  to  the  point  of  injection. 
This  inflammation  disappears  in  the  course  of  two  or  three  weeks.  The 


THE  ACUTE  INFECTIOUS  DISEASES 


665 


most  frequent  clinical  phenomena  of  antitoxin  therapy  are  the  serum  exan- 
themata, which  make  their  appearance  in  a  varying  percentage  of  cases  and 
usually  from  the  seventh  to  the  twelfth  day.     The  exanthem  commonly 
begins  at  the  point  of  injection  and  may  be  confined  to  this  immediate  re- 
gion (Fig.  169);  or  it  may  be  scattered         L 
irregularly  over  the  entire  body.   The 
most  common    form  is  an  urticarial 
erythema,  causing  intense  itching.   It 
often  appears  in  extraordinarily  large 
efflorescent  patches  with  measles-like 
areas  lying  between  them.    Sometimes 
the  entire  exanthem   resembles   that 
of  measles  which  it  simulates  the  more 
closely  in  the  fact  that  the  conjunc- 
tiva  are    occasionally   involved.      A 
most  uncommon  form  is  the  scarlati- 
noid  exanthem,  which  is  most  likely 
to  cause  diagnostic  difficulties,  since 
the   opportunity  of   acquiring  scarlet 
fever  in  wards  reserved  for  diphtheria, 
is    often  given.      The  fact  that  the 
serum    exanthem  does  net  affect  the 
mucous   membranes  of  the  mouth  is 
important  in  the  matter  of  differential 
diagnosis.    It  is  often  accompanied  by 
fever  \vhich  may  continue  for  several 
days  (see  Fig.  170).     Arthritic  pains 
occasionally,  but  less  commonly,  occur. 
During  the  course  of  serum  disease  a 
distinct  leucopenia  is  observed  as  a 
result    of   the   decrease  of  the  poly- 
morphonuclear    cells.       Occasionally 
precipitins,  acting  against  the  foreign 
serum,  may  be  demonstrated  in  vitro. 
The  human  organism  responds  dif- 
erently  to  the  reinjection  of  serum. 
If  such  reinjection  is  made  within  a 
period  of  from  twelve  days  to  three  or 
even  six  months  indications  of  disease 
appear  very  rapidly.     These  may  de- 
velop as  an  immediate  reaction  within  a  few  minutes  or  in  some  hours 
after  the  reinjection,  if  the  first  injection  had  caused  anaphylaxis.    Usually 
intense  edema  and  erythema  appear  at  the  site  of  injection.    More  rarely 
an  intense  edema  of  the  face  and  a  general  urticaria  appear,  sometimes 
associated  with  dyspnoea  and  alarming  collapse.     These  manifestations 
commonly  disappear  very  speedily.     If  readministration  of  the  serum  is 
postponed  later  than  from  three  to  six  months,  the  symptoms  are  apt  to 


666  TEXT-BOOK  OF  PEDIATRICS 

resemble  those  following  the  first  injection,  excepting  that  they  appear  at 
an  earlier  date,  generally  within  three  to  six  days.  This  idiosyncrasy  may 
persist  for  many  years,  so  that  from  the  appearance  of  such  symptoms  a 
previous  use  of  antitoxin  may  be  determined.  Certain  individuals  are  pre- 
disposed to  the  primary  as  well  as  the  anaphylactic  reaction.  Both  forms 
are  exceptional. 

Serum  disease  depends  upon  the  formation  in  the  organism  of  antibodies 
to  the  injected  serum.  These  antibodies  are  ordinarily  formed  in  from  seven 
to  twelve  days  after  the  first  injection  and  they  are  found  in  the  circulation 
for  several  succeeding  months. 

Upon  subsequent  occasion  they  may  be  formed  more  readily,  resulting 
in  the  more  rapid  reaction.  In  view  of  the  small  quantities  of  serum  used 
in  diphtheria,  serum  disease  is  uncommon  and  ordinarily  light.  In  scarlet 
fever,  however,  in  which  large  doses  of  100  or  200  c.c.  are  required  it  is 
often  a  very  serious  matter.  Consequently  scarlet  fever  serum  is  used 
only  in  severe  cases.  In  some  instances  the  immediate  reaction  may  be 
very  intense  and  may  cause  much  anxiety.  Nor  may  the  possibility  of  a 
fatal  termination  be  wholly  excluded,  extremely  uncommon  as  is  the  event. 
The  cause  of  this  sudden  death  is  not  yet  clear.  The  possibility  of  its  oc- 
currence emphasizes  the  fact  that  prophylactic  injections  should  not  be 
advised  without  very  substantial  reasons.  The  danger  of  anaphylaxis 
suggests  the  desirability  of  the  use  of  the  serum  of  some  other  species 
of  animal,  such  as  the  sheep,  for  prophylactic  purposes. 

The  question  arises  whether  all  diphtheritic  cases  should  be  treated 
with  antitoxin.  This  is  not  considered  necessary.  The  writer  believes  that 
the  expectant  treatment  of  slight  localized  diphtheria  of  the  tonsils,  in 
children  of  six  to  eight  years,  is  justified,  provided  they  can  be  watched 
carefully.  No  serious  injuries  have  resulted  from  this  practice.  While 
it  is  realized  that  this  position  will  be  combated  by  many,  reasons  have 
not  been  found  for  withdrawal  from  it.  For  those  whose  experience  in  weigh- 
ing the  severity  of  cases  is  limited,  it  may  be  better,  perhaps  to  choose  the 
easier  course  and  inject  every  patient.  Similarly  it  is  not  deemed  necessarjr 
to  give  prophylactic  injections  to  strong  healthy  children  of  over  two  years 
of  age  who  have  been  exposed  to  diphtheria,  but  are  under  constant  obser- 
vation; since  the  danger  of  anaphylaxis  appearing  if  a  later  injection  becomes 
necessary,  cannot  be  overlooked.  Since  passive  immunity  disappears  after 
about  three  weeks  a  prophylactic  injection  would  need  to  be  repeated  fre- 
quently in  order  to  prevent  infection. 

It  may  be  that  Behring's  diphtheria  vaccine  will  prove  of  great  service 
in  this  respect.  This  causes  an  active  formation  of  antitoxin,  giving  an 
immunity  which  lasts  for  a  longer  time.  Furthermore,  it  is  to  be  remem- 
bered that  many  persons  who  have  not  had  diphtheria,  nevertheless  pos- 
sess specific  antibodies  and  cannot  be  infected  with  the  disease.  These 
number  as  high  as  eighty  per  cent,  among  the  new-born  and  from  fifty  to 
sixty  per  cent,  among  older  children.  Intracutaneous  vaccination  with 
minute  quantities  of  diphtheria  toxin  produces  no  reaction  in  these  individ- 
uals (Shick),  showing  that  the  prophylactic  injection  of  serum  is  unnecessary. 


THE  ACUTE  INFECTIOUS  DISEASES  667 

Some  French  authors  recommend  the  daily  injection  of  large  doses  of 
antitoxin  in  severe  cases  of  diphtheria  and  in  the  event  of  royocardial  or 
paralytic  sequelae.  The  experience  of  other  writers  accords  with  our  own 
observations  in  throwing  doubt  upon  this  procedure.  This  method  has 
been  employed,  however,  in  a  number  of  cases,  with  the  injection  of  2000 
I.  U.  every  two  days.  Probably  it  has  been  useful  in  some  instances  and 
has  proved  injurious  in  none.  Certain  authorities  cite  good  results  in  severe 
paralyses  with  very  large  doses  of  serum  (20,000  -  50,000  I.  U.). 

The  question  as  to  the  time  to  use  antitoxin  is  to  be  further  considered. 
It  has  been  already  said  that  the  injection  should  be  given  as  early  as  pos- 
sible. In  doubtful  or  indefinite  cases  it  should  be  employed  immediately 
and  even  without  awaiting  the  report  of  the  bacteriologist,  since  very  valu- 
able time  may  be  lost  and  life  endangered  by  delay.  Certain  cases,  in  which 
postponement  of  the  use  of  antitoxin  is  justified,  have  been  mentioned. 

No  other  form  of  treatment,  accompanying  the  serum,  is  necessary, 
unless  operative  interference  is  indicated  for  the  relief  of  stenosis  of  the  larynx. 

Local  treatment  of  the  pharynx  by  pencilling  and  insufflation,  formerly 
so  common,  is  an  unnecessary  annoyance  and  may  do'  harm  because  of 
the  fear  it  excites  in  the  mind  of  the  patient.  General  hygiene  of  the  mouth, 
however,  is  indicated.  Older  children  should  be  required  to  rinse  the  mouth 
and  gargle  the  throat  with  a  weak  solution  of  boric  acid  or  hydrogen  per- 
oxide (1  per  cent.).  In  younger  children  an  attempt  should  be  made  to 
cleanse  the  mouth  by  spraying  or  irrigation  with  a  2  per  cent,  solution  of 
hydrogen  peroxide,  if  it  can  be  done  without  arousing  too  much  antagonism. 
Forceful  measures  are  justified  only  in  extreme  cases  of  gangrenous  phar- 
yngeal  diphtheria  and  even  then  their  benefit  is  doubtful.  In  robust  chil- 
dren frequently  renewed  cold  packs  or  ice-bags  may  be  applied  to  the  neck. 
These  may  be  exchanged  later  for  hot  applications. 

In  nasal  diphtheria,  also,  the  local  treatment  is  secondary  to  the  serum 
therapy.  Efforts  should  be  confined  to  careful  removal  of  the  secretions 
by  means  of  cotton  tampons  and  to  the  protection  of  the  upper  lip  from 
erosion  by  the  use  of  a  bland  ointment.  If  desired,  powdered  bolus  alba 
may  be  blown  carefully  into  the  nostrils  every  hour,  as  described  by  Trumpp. 
In  ocular  diphtheria  the  phenol-free  serum  may  be  instilled  directly  into  the 
conjunctival  sac,  combining  this  treatment  merely  with  frequent  cleansing 
and  cold  applications. 

In  early  laryngeal  diphtheria  a  moist  warm  general  pack,  inducing  per- 
spiration, may  act  favorably.  Frequently  renewed  hot  applications  may  be 
placed  about  the  neck.  Apart  from  the  general  quieting  effect  they  pro- 
duce, there  is  no  special  indication  for  such  narcotics  as  codein  or  morphin. 
The  constant  impregnation  of  the  atmosphere  with  steam  from  a  0.5  per 
cent,  solution  of  sodium  chloride  is  obviously  beneficial.  Special  rooms  are 
equipped  for  this  purpose  in  hospitals.  In  the  home,  resort  must  be  had 
to  the  steam  atomizer  or  croup  kettle  (Fig.  95).  If  this  is  impossible  a  pail- 
ful of  boiling  water  may  be  placed  near  the  bed  and  the  latter  covered  with 
an  improvised  tent.  If  the  laryngeal  stenosis  increases,  despite  the  use  of 
antitoxin  and  of  these  subsidiary  measures,  the  threatening  danger  of  me- 


668  TEXT-BOOK  OF  PEDIATRICS 

chanical  closure  of  the  glottis  should  be  met  unhesitatingly  by  intubation 
or  tracheotomy. 

The  general  treatment  of  diphtheria  even  in  its  milder  forms,  requires 
great  care.  Considering  the  great  liability  of  the  heart  to  injury,  all  un- 
necessary excitement  and  the  infliction  of  pain  must  be  avoided  so  far  as 
possible.  This  should  include  all  unnecessary  exercise  even  in  the  use  of 
toilet  conveniences. 

The  diet  frequently  presents  great  difficulties.  Because  of  the  embar- 
rassment in  swallowing  it  must  be  confined  to  liquids.  It  may  be  better  to 
give  small  quantities  of  food  every  hour  or  two  if  there  is  obstinate  anorexia. 
At  the  outset,  milk  gruels,  thin  farinaceous  puddings,  cocoa  and  egg  may 
be  given,  with  a  little  coffee  to  serve  as  a  stimulant.  In  severe  protracted 
cases,  freshly  expressed  meat-juice  will  prove  useful.  Fresh  fruit  juices,  such 
as  grape,  orange  and  lemon,  for  younger  children  and  stewed  apple,  for 
older  ones,  form  a  welcome  addition  to  the  limited  menu.  Later,  the  child 
may  be  allowed  soft  toast,  finely-mashed  spinach,  riced  potato,  chopped 
meat,  etc.  Plenty  of  fresh  water  should  be  given.  While  the  laryngeal 
tube  is  in  place  the  difficulty  of  swallowing  either  fluids  or  solids  is  of- 
ten increased  and  it  is  better  to  give  all  food  in  a  semi-liquid  form.  This 
rule  applies,  also,  in  paralysis  of  the  pharynx.  By  the  addition  of  a  very 
small  quantity  of  gelatin  (1-2  per  cent.),  milk  is  very  readily  brought  to 
this  consistency. 

As  long  as  there  are  signs  of  cardiac  weakness  or  of  marked  lassitude, 
the  patient  should  be  kept  in  bed  and  that  even  though  the  local  symptoms 
and  the  fever  have  been  absent  for  weeks.  This  is  rot  to  say  that  slight 
irregularities  of  the  pulse,  with  an  otherwise  normal  heart,  which  may  per- 
sist for  months,  constitute  a  reason  for  confining  the  patient  to  bed.  Dur- 
ing the  acute  stage  stimulants  are  often  necessary.  At  this  period,  as  well 
as  in  postdiphtheritic  myocarditis,  caffein  and  camphor  may  be  employed. 
In  myocardial  complications  the  combined  use  of  caffein  and  digitalis  seems 
to  be  efficient.  In  the  event  of  serious  vasomotor  disturbances,  which  in 
grave  cases  set  in  rapidly,  epinephrin  (1:1000),  in  large  doses,  will  often 
give  satisfactory  results.  It  is  given  subcutaneously  in  doses  of  0.5-1.0  c.c. 
(minims  viii-xv)  in  10-15  c.c.  (3  u'-iii)  of  physiologic  saline  solution. 

The  postdiphtheritic  paralyses  of  moderate  degree  recover  without 
treatment.  Injections  of  strychnia  are  commonly  used  but  are  of  doubtful 
value.  They  are  given  from  three  to  five  times  a  week  using  from  0.5-2 
milligrams  (gr.  M^o-Mo),  according  to  the  child's  age.  In  severe  cases  re- 
peated daily  injections  of  large  doses  of  antitoxin  (2000-4000  I.  U.),  may 
be  tried  as  a  last  resort.  There  is  no  objection  to  the  careful  use  of  elec- 
tricity to  the  affected  nerves. 

During  the  abatement  of  symptoms  and  in  convalescence,  quinine  and 
iron  preparations  are  useful.  Removal  to  the  country  is  to  be  recommended. 
The  complications  of  diphtheria  are  to  be  treated  in  the  customary  manner. 
Diphtheritic  nephritis  requires  no  special  attention. 

The  exact  time  at  which  operative  interference  is  indicated  cannot  be 


THE  ACUTE  INFECTIOUS  DISEASES  669 

stated  within  hard  and  fast  lines.  Generally  speaking,  it  should  be  under- 
taken whenever  the  stenosis  causes  marked  retraction  of  the  epigastrium 
and  the  suprasternal  notch,  or  when  a  progressively  increasing  cyanosis 
becomes  so  intense  as  to  induce  stupor  or  attacks  of  suffocation.  Even  if 
the  cyanosis  is  not  excessive,  but  the  constant  stenosis  and  the  labored 
respiration  threaten  exhaustion,  the  operation  should  not  be  delayed.  In 
the  home  the  operation  must  be  undertaken  sufficiently  early.  In  the 
hospital,  where  the  patient  is  under  constant  expert  observation,  greater 
delay  is  permissible.  For  those  who  crave  a  more  dogmatic  rule  it  may  be 
said,  that  the  proper  tune  for  interference  is  when  the  sternomastoid  is 
employed  as  an  auxiliary  in  respiration.  The  contraction  of  this  muscle 
is  readily  recognized  by  palpation.  Placing  the  thumb  and  the  forefinger 
along  the  lower  part  of  the  outer  edge  of  the  muscle  one  may  feel  the  con- 
traction during  inspiration.  This  may  also  be  accomplished  by  holding  the 
muscle  between  the  thumb  and  the  forefinger  at  various  levels. 

With  the  necessity  for  operative  interference  arises  the  question  of 
choice  between  tracheotomy  and  intubation.  Intubation  is  generally  to  be 
preferred,  without  reservation,  as  soon  as  the  physician  has  acquired  some 
practice.  Tracheotomy  has  become  less  and  less  popular  in  most  clinics. 
Parents  who  object  to  the  use  of  the  knife  usually  give  their  ready  assent 
to  this  bloodless  procedure.  It  requires  less  than  a  minute  in  its  perform- 
ance and  can  be  done  without  anesthesia  or  expert  assistance.  Such  acci- 
dents as  asphyxia  from  the  downward  displacement  of  a  piece  of  membrane, 
etc.,  are  rare,  but,  nevertheless,  preparation  for  tracheotomy  must  always 
be  made  lest  such  mishap  should  occur.  Hemorrhage  and  wound  infections 
do  not  occur.  The  tube  is  often  permanently  removable  from  the  first  to 
the  third  day. 

A  contraindication  for  intubation  is  seen  in  the  existence  of  pharyngeal 
stenosis,  as  a  result  of  an  extraordinary  hypertrophy  of  the  tonsils.  Serious 
embarrassment  occasionally  results  from  an  obstinate  difficulty  in  swallow- 
ing, the  repeated  coughing  up  of  the  tube,  and  subsequent  laryngeal  decu- 
bitus.  .  But,  in  comparison,  the  objections  to  tracheotomy  are  many  and 
serious.  It  demands  trained  assistance  and  anesthesia;  it  involves  the 
danger  of  hemorrhage  and  of  wound  infection;  a  longer  time  elapses  before 
the  canula  can  be  removed;  frequently  occurring  sequelae,  such  as  vocal 
impairment,  decubitus  and  trachea!  stenosis  result.  The  effects  of  intu- 
bation properly  performed  are  at  least  as  good  as  those  of  tracheotomy,  so 
that  it  is  always  to  be  preferred.  Most  podiatrists  reserve  tracheotomy  for 
secondary  use  in  cases  where  the  tube  cannot  be  removed  for  four  to  six 
days,  when  danger  of  decubitus  ensues.  Tracheotomy  is  advisable  also  in 
cases  in  which  intubation  does  not  relieve  the  stenosis  or  when  the  obstruc- 
tion recurs  speedily.  In  some  of  the  cases  the  difficulty  is  due  to  bronchial 
croup  and  tracheotomy,  therefore,  does  no  greatergood.  Occasionally  trache- 
otomy relieves  the  situation  by  encouraging  the  more  complete  removal 
and  expectoration  of  the  deep-seated  membrane. 

Tha  method  of  intubation  most  frequently  employed  is  after  the  simple 
procedure  devised  by  O'Dwyer.  A  bronze  or  ebonite  tube  of  appropriate 


670 


TEXT-BOOK  OF  PEDIATRICS 


form  is  introduced  into  the  narrowed  glottis  through  the  mouth  by  means 
of  a  specially  devised  instrument.  The  patient  is  held  upon  the  lap  of  the 
mother  or  nurse.  The  upper  part  of  the  body  is  wrapped  in  a  blanket,  which 
serves  to  confine  the  arms,  and  the  lower  extremities  are  held  between  the 
knees  of  the  attendant.  The  mouth  is  held  open  by  a  mouth-gag,  preferably 
of  the  Whitehead  type,  which  is  self-retaining.  The  head  must  be  held 
perfectly  straight  and  must  not  be  bent  backward.  The  physician  sits 
upon  a  low  stool  directly  in  front  of  the  patient.  The  forefinger  of  the  left 
hand,  introduced  into  the  pharynx,  palpates  the  epiglottis  and  the  aryte- 
noid  cartilages  and  draws  the  epiglottis  and  the  tongue  sharply  forward. 

The  intubator,  armed  with  the 
threaded  tube,  is  held  firmly  in 
^^Mtofc.  the  right  hand  and  the  tube  is  in- 

>bgflB  •  •       H  troduced  horizontally  between  the 

•        •  W^?  teeth  and  exactly  in  the  median 

^^  \  line  of  the   pharynx  (Fig.  171). 

^M  -^te  Hk    ^e  l°wer  end  °f  the  tube  lies  at 

the  radial  side  of  the  left  index 
finger  and  is  passed  along  this  to 
its  point,  during  which  movement 
the  handle  of  the  intubator  is 
gradually  brought  to  the  horizon- 
tal. The  left  index  finger,  exerting 
constant  traction  on  the  epiglottis 
gives  way  toward  the  ulnar  side, 
while  the  end  of  the  tube  at  its 
radial  side  is  pushed  downward, 
entering  the  glottis.  This  is  the 
more  easily  accomplished  during 
an  inspiration,  since  the  epiglottis 
is  widely  opened  at  that  time.  The 
entrance  to  the  larynx  may  be 
covered  with  the  tip  of  the  finger 
for  a  moment.  When  it  is  un- 
covered the  child  usually  takes  a  deep  breath  and  this  is  used  to  advance 
the  tube.  When  about  one-third  of  the  tube  has  been  introduced,  the  pal- 
pating finger  is  passed  around  it  to  see  that  it  is  properly  placed.  The 
tube  must  be  entirely  surrounded  by  mucous  membrane.  Then  the 
intubator  is  withdrawn,  by  placing  the  tip  of  the  finger  on  the  edge  of 
the  tube  and  pressing  it  completely  into  the  larynx,  again  palpating  the 
entire  area  to  make  certain  that  the  head  of  the  tube  is  completely  sur- 
rounded by  mucous  membrane.  The  free  end  of  the  thread  attached  to 
the  tube  is  left  projecting  from  the  left  angle  of  th°  mouth  and  is 
fastened  to  the  cheek  with  adhesive  tape.  The  entire  procedure  requires 
but  a  few  seconds.  It  should  be  carried  out  very  carefully;  no  force  is 
permissible.  If  the  tube  is  correctly  placed  in  the  larynx,  its  presence 


FIG.  171. — Intubation  of  the  larynx.  The  mouth  is 
held  open  by  means  of  a  Whitehead  mouth-gag.  The 
tube  is  being  passed  along  the  radial  side  of  the  left 
index  finger  which  draws  the  epiglottis  forward,  into 
the  throat. 


THE  ACUTE  INFECTIOUS  DISEASES  671 

there  is  recognized  by  the  peculiar  metallic  tone  which  is  given  to  the 
breathing  and  the  cough.  The  beginner  sometimes  places  the  tube  in 
the  esophagus.  In  such  an  event  the  tube  must  be  withdrawn  by  means 
of  the  thread  and  the  operation  should  be  repeated  after  a  few  minutes  rest. 
An  artificial  passage  through  the  lower  constrictors  of  the  pharynx  can  be 
made  only  by  the  use  of  brutal  force. 

The  silk  thread  attached  to  the  head  of  the  tube  is  fastened,  as  described, 
to  the  left  cheek  with  adhesive  tape,  in  order  that  the  nurse  may  readily 
remove  the  tube  if  an  attack  of  suffocation  should  occur.  To  prevent  the 
child  from  pulling  out  the  tube  its  arms  may  be  tied  to  the  bed  or  be  held 
by  stiff  cuffs.  Any  difficulty  in  swallowing  caused  by  the  tube  usually  dis- 
appears within  a  day  or  two.  It  is  best,  however,  to  give  only  semi-liquid 
food.  The  discussion  of  other  methods  of  intubation  cannot  be  under- 
taken here. 

Sometimes  the  tube  is  coughed  out  after  a  few  hours  and  the  absence  of 
further  stenosis  makes  its  replacement  unnecessary.  If  it  remains  in  place 
and  the  fever  goes  down  the  next  day,  as  a  result  of  the  action  of  the  anti- 
toxin, the  physician  may  draw  out  the  tube  after  two  days  and  see  whether 
the  patient  is  able  to  breathe  without  it.  Severe  stenosis  often  appears 
immediately  or  within  a  few  hours.  Whether  thus  removed  by  the  physi- 
cian or  in  the  act  of  coughing,  the  stenosis  may  suddenly  become  alarming. 
For  this  reason  alone,  tracheotomy  is  preferable  when  the  case  is  to  be 
treated  at  home.  If  the  tube  has  to  be  replaced  after  the  first  removal, 
repeated  attempts  at  extubation  should  be  made  every  other  day.  In  most 
cases  treated  with  serum,  the  tube  may  be  left  out  permanently  after  three 
or  four  days.  If  this  does  not  prove  true  it  is  well  to  perform  a  tracheotomy 
in  four  to  seven  days.  Pain  in  swallowing  and  the  appearance  of  black 
spots  on  the  tube  indicate  decubitus.  This  is  especially  to  be  dreaded  in 
croup  occurring  in  the  course  of  measles.  It  may  develop  alike  after  intu- 
bation and  after  tracheotomy.  The  technic  of  tracheotomy  is  fully  de- 
scribed in  the  text-books  of  surgery. 

Tracheotomy  is  much  more  easily  performed  when  the  intubation  tube 
is  in  place.  In  severe  asphyxia,  narcosis  is  unnecessary.  Cricotracheofcomy 
should  always  be  avoided,  since  vocal  disturbances  are  sure  to  follow.  In 
the  presence  of  goitre,  the  superior  tracheotomy  is  to  be  preferred;  other- 
wise the  inferior  site  is  to  be  chosen.  If  the  field  of  operation  is  scrupulously 
confined  to  the  median  line  and  the  operator  and  his  assistant  each  hold 
the  soft  tissues  on  each  side  of  the  median  line  symmetrically  with  the 
forceps,  cutting  and  dissecting  with  the  greatest  care,  tracheotomy  is  easily 
performed  and  with  small  danger  of  encountering  any  large  vessels.  The 
first  attempt  at  permanent  removal  of  the  cannula  is  to  be  made,  at  the 
earliest,  on  the  fourth  or  the  fifth  day.  It  is  harmful  to  attempt  progressive 
decannulization  with  cannulae  of  diminished  size,  since  this  usually  leads  to 
the  formation  of  granulation  tissue. 

The  most  efficient  relief  in  difficult  decannulization  is  intubation  and, 
vice  versa,  the  most  efficient  relief  or  difficulty  in  extubation  is  tracheotomy. 


672  TEXT-BOOK  OF  PEDIATRICS 

PERTUSSIS  OR  WHOOPING-COUGH 

Pertussis  is  a  specific,  contagious  disease,  the  most  important  symptoms 
of  which  arise  from  the  respiratory  tract  and  excite  characteristic  attacks 
of  coughing.  The  disease  occurs  in  all  parts  of  the  world.  It  was  first 
described  in  the  seventeenth  century. 

The  causative  organism  has  been  sought  in  numerous  researches  and 
many  different  germs  have  been  described  as  producing  the  disease.  A 
bacillus  recently  discovered  by  Bordet  and  Gengou  is,  however,  the  only 
organism  that  appears,  with  any  degree  of  probability,  to  be  the  true  cause 
of  the  disease.  These  authors  have  consistently  found  a  peculiar  polymor- 
phous bacillus  in  the  sputum  of  patients  with  pertussis.  This  is  a  weakly 
staining  bacillus,  the  centres,  in  particular,  taking  the  stain  very  lightly 
(Fig.  172).  It  is  very  abundantly  present,  and  even  in  pure  culture,  in  the 
sputum  of  recent  cases.  Advanced  cases  show  them  less  numerously  but 

exhibit  large  numbers  of  saphrophytes.  This 
bacillus  is  found  in  no  other  disease.  It  is  ag- 
glutinated by  the  serum  of  individuals  con- 
valescing from  pertussis.  Its  viability  is  not 
great  and  it  does  not  resist  high  temperatures. 
Inaba  has  produced  pertussis  in  the  monkey 
by  inoculation  with  its  pure  culture 

Anatomy  and  Pathogenesis. — Since  deaths 
hardly  ever  occur  in  pertussis,  unless  compli- 
cations or  secondaiy  infections  develop,  the 
opportunity  to  study  the  pathology  of  the  dis- 
ease is  very  meagre.  The  pathologic  changes 
FIG.  172.— Pertussis  bacilli  are  evidently  very  slight  and,  aside  from  al- 

(Bordet-Gengou)  after  a  prepara-  ..  •  •      .1        111  •    ,  i       • 

tion  by  Prof.  c.  Trauken  in  Haiie.  terations  m  the  blood,  consist  merely  in  ca- 

tarrhal  conditions  of  the  upper  air  passages. 

Broncho-pneumonia,  foci  of  which  are  found  in  almost  every  case  that 
comes  to  autopsy,  is  the  most  frequent  cause  of  death.  It  must  be  re- 
garded as  a  secondary  infection.  The  tenacious,  glairy  mucus  is  probably 
the  cause  of  the  paroxysms  of  coughing,  acting  as  an  irritant  as  it  passes 
the  glottis,  the  posterior  angle  of  which  is  the  most  sensitive  point. 

The  contagion  in  pertussis  travels  almost  wholly  from  one  person  to 
another  and  is  probably  carried  in  the  sputum,  that  is  by  droplet  infection. 
The  secretion  of  the  upper  air  passages  seems  to  be  extraordinarily  infec- 
tious, since  contact  with  an  affected  patient  for  but  a  few  minutes  suffices 
for  the  conveyance  of  the  disease.  The  vast  numbers  in  which  the  Bordet- 
Gengou  bacillus,  is  present  in  the  sputum  of  recent  cases  satisfactorily  ex- 
plains the  rapid  spread  of  the  malady.  Indirect  transmission  of  the  disease 
by  healthy  persons  or  by  means  of  clothing  is  extremely  rare,  to  say  the 
least.  It  is  usually  supposed  to  have  taken  place  when,  as  a  matter  of 
fact,  transmission  has  occurred  through  the  agency  of  masked  cases. 

Its  contagiousness  is  marked  from  the  very  beginning  of  the  catarrhal 
stage,  when  it  still  requires  a  week  or  more  to  determine  the  true  character 


THE  ACUTE  INFECTIOUS  DISEASES 


673 


of  the  disease.  This  is  the  period  in  which  transmission  generally  occurs 
since  it  is  the  time  when  no  precautionary  measures  are  taken.  Further- 
more, the  contagion  is  at  its  height  at  this  stage.  It  continues  during  the 
convulsive  period,  but  its  virulence  lessens  rapidly.  In  the  stage  of  decline 
its  contagious  quality  is  very  slight  and  often  seems  to  disappear  entirely. 
It  is  safe,  however,  to  suppose  that  there  is  still  danger  of  conveyance  as 
long  as  the  child  coughs. 

At  times  the  prevalence  of  the  disease  amounts  to  an  epidemic.  This 
happens  most  frequently  in  small  communities,  while  in  large  cities  where 
cases  can  always  be  found  and  large  numbers  of  children  are  immune,  it 
hardly  ever  assumes  epidemic  proportions. 

The  predisposition  to  the  disease  is  very  general,  so  that  nearly  all  chil- 
dren who  have  not  had  it,  take  it,  if  ex- 
posed. No  age  is  exempt,  but  the  greatest 
liability  is  between  the  first  and  the  third 
year.  In  no  other  contagious  disease  is  in- 
fancy so  frequently  affected  as  in  pertussis 
(see  page  573) .  Many  children  are  attacked 
even  within  the  first  few  months  and  not 
infrequently  within  the  first  week.  Indeed, 
even  congenital  pertussis  has  been  reported 
when  the  mother  has  had  whooping-cough 
before  delivery;  the  new-born  infant  having 
a  characteristic  cough  on  the  first  day.  The 
authoVs  youngest  patient  was  ten  days  old. 
The  mother  had  pertussis.  It  may  be  well 
supposed  that  the  predisposition  is  as  great 
during  the  first  year  as  it  is  later.  If  fewer 
children  are  affected  with  the  disease  during 
this  period  than  in  the  second  or  third  year, 
it  may  be  fully  explained  by  the  slighter 
danger  of  infection — slighter  because  young 
infants  are  more  carefully  isolated  than  are  older  children  and  because 
many  first-born  are  not  exposed  in  infancy  at  all. 

One  attack  of  the  disease  confers  a  high  degree  of  immunity,  so  that  a 
second  is  extremely  rare.  When  second  infection  does  occur,  it  is  usually 
in  the  adult,  who  had  the  disease  in  childhood  and  is  later  exposed  to  re- 
infection by  close  contact  with  children  suffering  with  whooping-cough. 
The  markedly  greater  predisposition  of  females  is  quite  noticeable  at  all 
ages — a  fact  not  yet  accounted  for. 

The  constitutional  quality  of  the  child  exercises  an  influence  upon  the 
course  of  the  disease.  The  attack  is  more  severe  and  lasts  longer  in  nervous, 
neuropathic  and  spasmophilic  individuals. 

The  cold  season  causes  an  increased  sensitivity  of  the  respiratory  tract 
and  thus  favors  the  spread  of  pertussis. 

The  disease-picture  is  ordinarily  quite  monotonous  and  varies  chiefly 
in  the  intensity  of  the  individual  case.    For  purposes  of  description  a  case 
of  medium  severity  is  outlined. 
43 


FIG.  173. — Ulcer  of  the  frenula  of  the 
tongue  in  pertussis. 


674  TEXT-BOOK  OF  PEDIATRICS 

The  incubation  period  is  of  variable  duration.  On  the  average  it  covers 
about  one  week,  but  it  may  be  shortened  to  three  or  four  days  or  extended 
to  two  weeks.  It  is  safe  to  conclude  that  a  child  who  has  been  exposed  and 
does  not  develop  any  catarrhal  symptoms  within  fourteen  days  has  not 
been  infected. 

Since  its  very  first  recognition,  three  stages  of  pertussis  have  been 
noted;  a  catarrhal  stage,  a  convulsive  stage  and  the  stage  of  decline. 

The  catarrhal  stage  begins  with  slight  coryza  and  cough,  possibly  a 
little  hoarseness,  and  a  reddening  of  the  conjunctiva.  In  those  predisposed 
to  laryngeal  symptoms  the  disease  may  be  ushered  in  by  an  attack  of  pseudo- 
croup.  These  manifestations  last  from  one  to  two  weeks,  rarely  for  a  shorter 
or  a  longer  period.  During  the  first  few  days  slight  fever  may  develop  in 
some  few  cases,  even  before  distinct  catarrhal  signs  are  present.  At  the 
outset  there  is  nothing  to  distinguish  this  stage  from  ordinary  acute  catarrh. 
A  suspicion  of  pertussis  is  aroused  only  upon  information  of  exposure. 
Occasionally,  a  case  never  gets  beyond  the  catarrhal  stage  and  recovers 
without  a  diagnosis.  Usually,  however,  the  cough  becomes  more  and  more 
severe  without  the  development  of  any  bronchitic  signs.  Most  noticeable 
are  the  facts  that  ordinary  remedies  fail  to  relieve  the  cough;  that  the 
coughing  occurs  at  night  as  well  as  by  day  and  gradually  establishes  a 
certain  periodicity. 

The  catarrhal  phase  gradually  passes  into  the  convulsive  stage.  The 
cough  is  rather  less  frequent  but  it  occurs  at  regular  intervals,  even  during 
the  night.  The  attacks  assume  a  violent,  compellant,  intense  character 
and  proceed,  with  varying  rapidity,  toward  the  typical  quality  so  readily 
recognized.  The  spasms  of  coughing  are  often  ushered  in  by  restlessness 
and  discomfort.  The  child  senses  a  tickling  in  the  throat,  a  degree  of  pres- 
sure in  the  thorax;  it  becomes  frightened  and  runs  to  the  mother,  or  clutches 
any  convenient  object.  In  some  cases  initial  vomiting  occurs.  After  a 
deep  inspiration  a  succession  of  intense  coughs  follow  each  other  so  rapidly 
that  inspiration  is  arrested.  The  face  reddens,  the  conjunctiva  becomes 
injected  and  the  tongue  protrudes.  The  coughing  fit  is  followed  suddenly 
by  a  forced,  loud  inspiration  termed  the  "whoop,"  produced  by  the  violent 
indrawing  of  air  through  the  glottis,  which  is  still  in  a  state  of  spasmodic 
contraction.  But  the  attack  does  not  end  with  this  temporary  relief,  as 
may  be  seen  from  the  persisting  restlessness  of  the  child.  Repeated  spasms 
of  coughing  terminated  by  the  characteristic  whoops  follow.  These  attacks 
recur  several  times,  while  the  lips  and  tongue  become  more  and  more  cya- 
notic  and  in  severe  instances  quite  blue,  until  the  child  seems  threatened  with 
suffocation.  The  series  of  attacks  usually  end  when  the  patient  expecto- 
rates, with  difficulty,  the  accumulated  mass  of  tenacious  glairy  mucus.  In 
very  young  children  this  material  frequently  remains  in  the  pharynx. 
Should  the  attack  be  very  severe  it  is  followed  by  the  vomiting  of  all  food 
recently  taken.  Robust  children  will  recover  immediately  from  serious 
attacks  and  will  continue  their  interrupted  play  with  apparent  unconcern. 
The  younger  and  weaker  are  exhausted;  they  perspire  freely,  and  it  will 
be  some  time  before  they  recover  from  the  immediate  effects. 


675 

In  number  and  intensity  the  attacks  are  extraordinarily  variable.  They 
increase  progressively  during  the  convulsive  stage,  which  usually  lasts  from 
three  to  six  weeks.  Many  children  have  only  five  to  ten  attacks  in  the 
twenty-four  hours;  in  others  the  number  will  run  to  thirty,  fifty  or  even 
more.  The  individual  attacks  vary  similarly;  the  series  of  staccato  coughs 
and  the  reprisal  may  be  repeated  twice  to  five  times,  as  a  minimal,  and 
from  ten  to  thirty  times  as  a  maximal  range.  In  rare  cases  a  spasmodic 
sneezing  takes  the  place  of  the  coughing.  The  lungs,  in  uncomplicated 
cases,  present  normal  auscultation  sounds  or  scattered  coarse  rales  which 
disappear  for  a  time  after  each  attack.  Frequently,  however,  a  distension 
of  the  lungs  develops  during  the  convulsive  stage.  This  becomes  an  es- 
pecially marked  feature  in  infants.  In  severe  cases,  the  heart  shows  dilata- 
tion of  the  right  ventricle.  The  pulse-rate  is  increased.  Edema  of  the  face 
is  common  at  the  height  of  the  disease.  Fever  always  indicates  the  presence 
of  complications. 

When  whooping-cough  has  once  reached  its  maximal  intensity,  it  con- 
tinues for  several  days  or  weeks  at  its  height  and  then  enters  the  stage  of 
defervescence  and  declines  rapidly.  The  attacks  at  first  become  less  numer- 
ous but  remain  as  intense  as  ever.  Soon  the  intensity  likewise  decreases; 
the  vomiting  stops;  the  cough  occurs  but  rarely  and  loses  its  typical  character. 
A  simple  catarrhal  cough  may  persist  for  a  long  time. 

The  duration  of  the  entire  illness  varies  in  the  average  case  from  four  to 
ten  weeks,  provided  there  are  no  complications.  Even  with  a  favorable 
termination,  there  is  considerable  loss  of  weight.  Convalescence  is  com- 
monly rapid  in  the  absence  of  pulmonary  complications  which  may  lay  a 
foundation  for  tuberculous  infection.  If  bronchitis  sets  in  during  the  stage 
of  decline,  it  usually  causes  a  recrudescence  of  the  disease  or  the  reappear 
ance  of  frequent  and  intense  attacks,  which  again  disappear  speedily  with 
the  relief  of  the  bronchial  affection.  If  a  child  develops  any  ordinary  bron- 
chial catarrh,  weeks  or  months  after  a  complete  recovery  from  whooping- 
cough,  the  characteristic  quality  of  the  cough  of  pertussis  again  appears. 

VARIATIONS  IN  COURSE 

Sometimes  the  course  of  pertussis  is  completed  in  two  or  three  weeks. 
But  few  attacks  occur  and  often  these  are  not  typical.  At  other  times  an 
irritative  cough  persists  for  several  weeks  without  the  development  of  dis- 
tinct spasmodic  attacks.  The  diagnosis  of  this  mild  form  is  possible  only 
when  definite  cases  of  pertussis  are  to  be  found  in  the  immediate  neighbor- 
hood. Such  marked  cases  are  quite  common  in  late  childhood  and  among 
adults  and  naturally  favor  the  spread  of  the  disease. 

On  the  contrary,  extraordinarily  severe  cases  are  comparatively  few. 
Apparently  they  depend  either  upon  marked  predisposition  or  upon  exceed- 
ingly virulent  infection.  These  cases  in  the  beginning  show  a  distinct  fever. 
The  temperature  may  rise  as  high  as  39°  C.  (102°  F.).  The  general  well- 
being  is  seriously  impaired  by  restlessness  and  loss  of  sleep.  The  pulse  is 
rapid.  Dyspnoea  and  frequent  exhausting  attacks  of  coughing  and  vomit- 


676  TEXT-BOOK  OF  PEDIATRICS 

ing  soon  develop.    So  severe  a  type  of  the  disease,  without  any  marked 
complications,  may  lead  very  speedily  to  a  fatal  termination. 

Pertussis  in  young  infants  often  presents  peculiar  characters.  The 
attacks  of  coughing  occur  with  such  severity  as  to  cause  cyanosis  and  at 
times  persisting  apncea  with  ensuing  loss  of  consciousness,  eclamptic  attacks 
and  general  atony.  The  crowing  inspiration  at  the  close  of  the  paroxysms 
disappears  and  is  replaced  by  a  gurgling  and  choking  with  accumulated 
mucus.  Vomiting  in  these  cases  is  comparatively  uncommon.  In  the  ab- 
sence of  the  usual  symptoms  a  diagnosis  often  fails,  particularly  in  the 
early  months  of  life. 

SPECIAL  SYMPTOMS  AND  COMPLICATIONS 

In  ordinary  cases  the  general  well-being  is  not  greatly  disturbed.  At 
times  an  irritable  and  peevish  disposition  is  noted.  Fever,  after  the  first 
few  days,  almost  always  announces  complications  most  frequently  found 
in  the  respiratoiy  tract.  In  a  few  cases,  however,  simple  pertussis  is  at- 
tended by  slight  persistent  fever.  Complications  nearly  always  set  in  during 
the  convulsive  stage.  Many  of  these  are  the  direct  consequences  of  the 
intense  paroxysms  of  coughing  and  the  ensuing  venous  congestion. 

Dilatation  of  the  right  ventricle  of  the  heart  is  often  the  result  of  the 
severe  coughing  spasms  continued  for  a  long  period.  This  may  be  demon- 
strated by  percussion,  but  it  is  often  veiled  by  the  distension  of  the  lungs. 
In  these  severe  cases  it  is  impossible  to  determine  to  what  extent  a  persist- 
ently increased  pulse-rate  is  due  to  over-exercise  of  the  heart,  or  in  what 
measure  it  should  be  attributed  to  toxic  influence.  Actual  myocardial  dis- 
ease, endocarditis  and  pericarditis  are  rare  complications  of  whooping- 
cough.  Persistent  congestion  of  the  lungs  causes  an  accentuated  pulmonic 
second  sound.  Sudden  cardiac  death  is  rare. 

The  blood  often  shows  an  increased  number  of  leucocytes,  ranging 
up  to  20,000  or  more.  This  is  usually  due  to  a  multiplication  of  the  neu- 
trophiles  and  still  more  definitely  of  the  lymphocytes. 

Through  a  congestion  of  the  cervical  veins  severe  paroxysms  of  whooping- 
cough  cause  a  reddening  of  the  conjunctiva  and  an  edema  of  the  eyelids, 
frequently  spreading  to  the  entire  face  and  incompletely  disappearing  in 
the  intervals  between  the  attacks.  On  this  account,  children  suffering  with 
pertussis  often  show  a  peculiar  puffiness  of  the  face,  especially  marked  about 
the  eyes,  and  coincident  with  a  swelling  of  the  thyroid. 

During  the  paroxysms  the  frenum  of  the  protruded  tongue  is  injured 
by  pressure  against  the  lower  central  incisors,  causing  the  formation  of  a 
transverse  white  ulcer  (Fig.  173).  While  this  injury  to  the  tongue  may 
appear  in  the  event  of  coughs  of  other  origin,  or  even  independently  of  this 
symptom  altogether,  it  is  especially  common  in  pertussis  and  most  often 
occurs  in  children,  who  have  only  the  two  lower  incisors,  since  the  irritation 
of  the  frenum  is  then  most  severe. 

The  abdominal  strain  attendant  upon  the  spasmodic  coughing,  not  infre- 
quently develops  in  those  predisposed,  either  an  inguinal  hernia  or  a  prolapse 
of  the  rectum.  Involuntary  defecation  and  micturition  often  occur  with 
severe  paroxysms. 


THE  ACUTE  INFECTIOUS  DISEASES  677 

An  intense  venous  congestion  often  leads  to  a  rupture  of  the  delicate 
capillary  walls,  injured  possibly  by  the  disease  toxins,  and  cutaneous  hemor- 
rhages result.  Epistaxis  is  a  very  common  occurrence,  but  is  rarely  alarm- 
ing. At  times  bloody  expectoration  from  the  pharynx  or  the  bronchi  is 
observed.  Semilunar  extravasations  in  the  bulbar  conjunctiva  around  the 
cornea  are  comparatively  common.  Hemorrhages  in  the  eyelids  are  rare. 

The  most  frequent  and  the  most  dangerous  complications  are  those  of 
the  respiratory  tract.  It  is  doubtful  whether  even  coarse,  bronchial  rales 
can  be  considered  as  incident  to  pure  pertussis,  or  whether,  as  one  would 
prefer  to  believe,  they  are  to  be  regarded  as  evidences  of  complication. 
The  fact  that  many  healthy  children  throughout  the  entire  course  of  the 
disease  never  present  catarrhal  breathing  sounds  and  that  these  alterations 
are  especially  observed  in  the  cold  season  and  in  weak,  rickitic  children, 
supports  this  view.  As  long  as  only  occasional  coarse  rales  are  heard 
without  change  in  the  respiratory  rhythm  and  without  fever,  no  harm 
results.  Nevertheless,  the  presence  of  these  rales  should  prepare  the  clini- 
cian for  more  serious  developments,  since  they  are  often  but  the  precursors 
of  a  severe  bronchitis  or  of  a  fatal  broncho-pneumonia.  If  a  severe  bronchi- 
tis develops,  the  glairy  sputum  takes  on  a  yellowish-green  color  and  an 
ordinary  catarrhal  cough  more  or  less  frequently  occurs  in  the  intervals 
between  the  paroxysms  of  whooping-cough.  In  children  of  three  or  four 
years  or  over,  the  bronchitis  eventually  disappears  with  no  more  serious 
results  than  the  protraction  of  the  pertussis.  Associated  with  coryza  and 
bronchitis,  a  catarrhal  or  purulent  otitis  media,  of  usually  benign  character, 
may  appear. 

In  young  children,  and  particularly  in  those  who  are  rickitic  and  weakly, 
bronchitis  has  a  great  tendency  to  lead  to  broncho-pneumonia.  At  the 
onset  this  transition  is  often  unrecognized,  on  account  of  the  presence  of 
only  small  scattered  foci  of  invasion.  It  is  sooner  suggested  by  dyspnrea 
and  by  a  more  intense  and  remittent  fever  than  by  the  demonstration  of 
dulness.  The  paroxysms  of  coughing  frequently  lose  their  typical  char- 
acter when  a  broncho-pneumonia  or  an  accidentally  intercurrent  lobar  pneu- 
monia develops.  They  grow  shorter  and  the  whoop  is  weakened  or  is 
entirely  lost,  while  the  cyanosis  remains.  After  the  pneumonia  is  over  the 
paroxysms  reappear  in  typical  form.  Capillary  bronchitis,  as  a  complica- 
tion of  pertussis,  is  a  less  common  event. 

A  progressive  and  extremely  dangerous  broncho-pneumonia  is  particu- 
larly frequent  when  measles  occurs  coincidently  with  pertussis.  Extensive 
changes  in  the  lung  favor  the  occurrence  of  convulsions. 

Broncho-pneumonia,  in  these  cases,  follows  a  very  protracted  course 
and  is  extremely  obstinate  as  long  as  intense  paroxysms  of  coughing  occur. 
Etiologically,  the  condition  is  generally  due  either  to  the  strepto-  or  pneu- 
mococcus.  The  latter  gives  the  more  benign  form. 

Pertussis  often  causes  pulmonary  emphysema,  revealed  by  the  promi- 
nence of  the  thorax  and  the  low  position  of  the  lung  border  anteriorly  on 
the  right  side.  The  increased  expiratory  pressure  leads  to  a  diffuse  bron- 
chiectasis,  giving  no  clinical  symptoms  but  often  determined  at  autopsy. 


678  TEXT-BOOK  OF  PEDIATRICS 

Permanent  bronchiectasis  following  pertussis  is  rare,  nor  does  pulmonary 
emphysema  very  often  remain,  and  generally  only  in  those  cases  which 
show  an  asthmatic  tendency.  Intense  coughing  may  cause  rupture  of  the 
alveoli  which  exceptionally  leads  to  an  interstitial,  a  mediastinal,  or  even  a 
subcutaneous  emphysema  and,  in  turn,  to  severe  dyspnoea  and  death.  This 
protracted  form  of  broncho-pneumonia  resembles  the  type  of  the  disease 
associated  with  tuberculosis.  The  differentiation  is  all  the  more  difficult, 
because  a  latent  tuberculosis  frequently  becomes  active  during  an  attack 
of  pertussis  and  generally  takes  the  form  of  tuberculosis  of  the  bronchial 
lymph  nodes  or  of  broncho-pneumonia  arising  from  the  hilus.  The  possibil- 
ity of  tuberculous  infection  must  always  be  considered  when  a  .young  child 
who  has,  or  has  recently  had  whooping-cough,  shows  emaciation,  anemia 
and  an  irregular  fever.  A  positive  cutaneous  reaction  to  tuberculin  must 
be  accepted,  even  in  the  absence  of  adequate  lung  findings,  in  such  a  case. 
In  older  children  simple  broncho-pneumonia  is  uncommon  and,  therefore, 
positive  pulmonary  findings  become  more  suggestive  of  tuberculosis.  In 
younger  children  a  negative  tuberculin  reaction  is  often  an  aid  to  the  exclu- 
sion of  tuberculosis. 

Next  to  the  respiratory  tract,  the  nervous  system  is  apt  to  be  involved  in 
pertussis.  Its  previous  condition  has  a  determining  influence  upon  the 
course  and  gravity  of  the  disease.  In  the  neurotic  or  neuropathic  the  parox- 
ysms of  coughing  are  more  frequent  and  more  severe  than  they  are  apt  to 
be  in  the  normal  individual.  Excitement  or  pain  to  which  they  may  be 
subjected  readily  brings  on  an  attack. 

When  a  number  of  children  suffering  with  pertussis  are  together  in  a 
single  room  and  one  of  them  goes  into  a  paroxysm,  all  the  rest  may  join  in 
the  chorus.  Older  children  are  often  able  to  suppress  an  attack  by  sheer 
force  of  will  and  may  even  be  stimulated  to  do  so  by  threats.  It  is  recorded 
of  the  wife  of  a  certain  general  that  she  cured  her  children  of  whooping- 
cough  with  the  rod.  An  anxious  or  restless  demeanor  upon  the  part  of  other 
members  of  the  family  has  a  bad  influence  upon  the  patient,  while  his  recov- 
ery is  favored  by  quiet  and  sensible  behavior.  It  would  be  a  dangerous 
perversion  of  facts,  of  course,  to  argue  that  the  nervous  constitution  of  the 
patient  is  any  more  than  an  aggravating  influence,  or  to  regard  pertussis  as 
a  nervous  disease  or  as  merely  the  reaction  of  the  neuropathic  to  various 
catarrhs!  infections  of  the  respiratory  tract. 

In  very  young  children  the  spasm  of  the  glottis  which  causes  the  crow- 
ing inspiration  at  the  close  of  the  paroxysm  of  coughing  often  becomes  very 
severe  and  may  lead  to  a  long  continued  closure  of  the  aperture.  This  may 
induce  apnoea,  a  profound  degree  of  cyanosis,  and  the  loss  of  consciousness. 
Quite  frequently  slight  twitching  of  the  facial  muscles  is  added  to  the  spasm 
of  the  glottis.  Even  a  general  eclamptic  condition  lasting  for  several  min- 
utes, with  prolonged  loss  of  consciousness,  has  been  observed.  Not  infre- 
quently general  convulsions  follow  a  severe  spasm  of  the  glottis  in  the 
young  infant.  These  convulsions,  indeed,  may  appear  independently  of 
and  in  the  intervals  between  the  attacks.  The  very  great  majority  of 
children  in  whom  the  spasm  of  the  glottis  is  accompanied  by  eclampsia  of 


THE  ACUTE  INFECTIOUS  DISEASES  679 

very  intense  degree,  and  even  threatening  life,  are  spasmophilic.  In  fact 
the  prognosis  of  pertussis  in  the  spasmophilic  is  always  grave.  In  infancy, 
sudden  death,  in  the  midst  of  these  severe  convulsions,  is  not  uncommon. 
Some  writers  assert  that  eclamptic  convulsions  in  pertussis  are  always 
indicative  of  this  constitutional  disturbance,  but  with  this  view  the  author 
is  not  agreed.  The  possibility  of  cerebral  irritation  as  a  result  of  venous 
congestion  and  often  as  a  result  of  deeper  organic  changes  is  to  be  consid- 
ered. Neurath  and  others  have  found  that  edema  and  true  infiltration  of 
the  pia  mater  occur  in  pertussis.  Occasionally,  severe  cerebral  disturbances 
occur  which  must  arise  from  an  organic  lesion.  Sudden  hemiplegia,  appear- 
ing during  a  severe  paroxysm  is  only  occasionally  due  to  cerebral  hemorrhage. 
Central  blindness,  deafness,  flaccid  paralyses,  imbecility,  confusion,  pares- 
thesias,  conditions  which  are  fortunately  of  rare  occurrence  and  usually 
transitory,  are  supposably  traceable  to  the  same  cause. 

Aside  from  the  edema  and  the  subcutaneous  hemorrhages  already  noted, 
the  skin  is  rarely  affected  in  pertussis.  Erythemata  are  very  uncommon. 

The  digestive  system  is  but  little  disturbed  in  the  majority  of  cases. 
Very  often,  however,  vomiting  occurs  at  the  close  of  a  paroxysm.  In  nervous 
individuals  this  may  be  very  obstinate  and  may  lead  to  actual  inanition, 
especially  when  it  is  combined  with  anorexia.  Diarrhoea  is  uncommon.  In 
children  of  one  or  two  years  of  age  it  is  to  be  dreaded  because  it  may  impair 
the  nutrition  seriously. 

Enlargement  of  the  liver  occasionally  occurs  in  pertussis  as  a  result  of 
congestion.  Enlargement  of  the  spleen  is  rare.  Albuminuria  is  demon- 
strated in  some  severe  cases.  True  nephritis  is  a  great  exception. 

The  diagnosis  of  pertussis  is  very  easily  made  in  advanced  cases,  if  the 
physician  is  present  during  a  paroxysm.  It  is  especially  easy  of  recognition 
when  several  children  of  a  family  are  simultaneously  affected.  If  necessary, 
a  paroxysm  may  be  brought  on  if  some  interval  of  time  has  elapsed  since 
the  last  one.  This  is  most  readily  done  by  introducing  a  tongue  depressor 
well  back  in  the  mouth  and  pressing  the  tongue  down  forcibly.  If  this  does 
not  suffice,  compression  of  the  larynx  or  trachea  from  without,  will  often 
bring  on  an  attack. 

If  the  physician  cannot  observe  a  paroxysm,  the  diagnosis  may  often  be 
made  from  the  history  of  attacks  of  coughing  occurring  at  regular  intervals 
and  even  during  the  night,  ending  in  a  "whoop,"  and  followed  by  the 
expectoration  or  hawking  up  of  a  tenacious  mucus,  causing  vomiting.  In 
coughs  of  other  origin,  children  of  less  than  eight  or  ten  years  are  not  apt  to 
bring  up  sputum,  so  that  any  young  child  who  does  may  be  suspected  of 
whooping-cough.  The  regular  appearance  of  the  paroxysms,  and  their 
continuance  through  the  night,  together  with  the  lack  of  objective  lung 
findings,  speak  definitely  for  pertussis.  Frequently  signs  of  congestion 
about  the  face,  the  presence  of  an  ulcer  on  the  frenum  of  the  tongue  and 
indications  of  hemorrhage  in  the  eyes,  etc.,  assist  the  diagnosis.  A  decision 
becomes  very  difficult  or  even  impossible  when  there  is  only  an  irritative 
cough  without  distinct  paroxysms,  and  particularly  in  the  catarrhal  stage 
before  their  paroxysmal  quality  has  developed.  Without  a  knowledge  of 


680  TEXT-BOOK  OF  PEDIATRICS 

the  disease  in  the  immediate  neighborhood,  or  without  the  discovery  of  a 
known  source  of  infection,  diagnosis  must  often  be  reserved  to  a  later  period. 

In  the  differential  diagnosis  of  pertussis,  certain  diseases  of  the  upper 
air  passages,  tuberculosis  of  the  bronchial  lymph  nodes,  and  hysteria  must 
be  considered.  Adenoid  vegetations  and  recent  pharyngeal  catarrh  often 
causes  a  severe  cough,  which  may  occur  during  the  night  when  secretion 
flowing  into  the  throat  causes  some  irritation.  Such  coughing  spells  are, 
however,  irregular  and  frequent,  but  they  do  not  increase  in  severity,  nor 
assume  a  paroxysmal  form.  Certain  forms  of  la  grippe  produce  a  severe 
and  persistent  cough,  which  may  excite  vomiting.  The  occurrence  of  marked 
and  frequent  paroxysms  of  coughing  at  the  outset  of  the  disease,  with  the 
development  of  fever  and  rales,  argue  against  pertussis.  The  cough  which 
results  from  enlargement  of  the  bronchial  lymph  nodes  is  very  similar  to 
that  of  whooping-cough.  Frequently  it  has  a  paroxysmal  character.  As  a 
result  of  pressure  of  the  enlarged  glands  upon  the  vagus  it  may  become 
sufficiently  severe  to  cause  the  expectoration  of  mucus  and  vomiting.  The 
crowing  inspiration,  however,  is  lacking.  Such  a  cough  may  last  for  many 
months  without  the  noticeable  increase  or  decrease  of  severity  seen  in  per- 
tussis. Further,  there  are  usually  other  signs  which  point  to  the  basic 
disease.  Among  these  are  fever  of  irregular  course,  emaciation,  and  dulness 
in  the  intra-scapular  space,  while  characteristic  shadows  are  observed  in 
the  Roentgenogram.  Imitative  neuroses,  due  to  hysteria,  occur  only  in 
older  children  and  even  with  them  are  exceptional.  These  cases  are  differ- 
entiated by  the  absence  of  paroxysms  during  sleep. 

The  prognosis  is  determined,  primarily,  by  age.  In  children  of  three  or 
four  years,  or  more,  it  is  usually  favorable,  but  in  younger  children  the 
possibility  of  broncho-pneumonia  is  always  to  be  considered.  The  younger 
the  patient  the  greater  the  danger.  Nevertheless,  young  infants  often 
weather  the  attack  surprisingly  well.  The  greatest  mortality  is  found 
between  six  months  and  two  years  of  age,  in  a  word,  during  that  period  when 
spasmophilia  and  rickets  are  at  their  height.  These  two  disorders  increase 
the  mortality  of  the  disease  materially;  the  former  on  account  of  the  inten- 
sity of  the  spasm  of  the  glottis  it  induces  and  the  liability  to  eclampsia  it 
carries  with  it ;  the  latter  on  account  of  its  characteristic  tendency  to  severe 
bronchitis  and  broncho-pneumonia. 

There  is  danger  of  a  fatal  termination  in  debilitated  or  tuberculous 
infants  or  in  those  suffering  with  disturbances  of  nutrition.  The  prognosis 
also  depends  in  large  measure  upon  the  environment  and  the  kind  of  care 
the  patient  receives.  Frequently  bronchitis  or  a  tendency  to  it  persists  for 
months.  It  is  a  notable  fact  that  in  many  cases  an  attack  of  pertussis  seems 
to  determine  an  improvement  of  the  general  health. 

Prophylaxis. — The  heaviest  task  in  the  prophylaxis  of  pertussis  is  in  the 
protection  of  children  from  infection  until  after  their  third  or  fourth  year. 
This  is  not  impossible  with  the  carefully  tended  children  of  the  well-to-do, 
since  the  disease  is  directly  transmitted  in  practically  all  cases.  Children 
who  have  pertussis  or  are  under  suspicion  of  it  should  be  isolated  both 
within  and  without  the  family.  This  isolation  should  be  scrupulously 


THE  ACUTE  INFECTIOUS  DISEASES  681 

applied  in  day  nurseries  and  kindergartens.  During  an  epidemic  every 
child  suffering  with  a  coryza  or  cough  should  be  considered  a  suspect.  If  a 
case  of  whooping-cough  has  appeared  in  a  family,  the  separation  of  the  patient 
from  others  in  the  home  who  have  not  yet  had  the  disease  is  usually  in  vain. 
Should  the  isolation  be  attempted,  the  possibility  of  the  spread  of  the  infec- 
tion remains  for  the  lapse  of  fourteen  days  from  the  date  of  last  exposure. 
After  this  period,  the  children  who  are  well  may  be  permitted  to  associate 
with  other  children  if  they  show  no  sign  of  coryza  or  cough.  Children 
suffering  with  pertussis  should  not  be  permitted  to  appear  on  the  public 
streets  or  playgrounds.  Ordinarily  they  should  not  be  allowed  to  associate 
with  others  until  the  cough  has  entirely  disappeared.  School  children  may 
be  readmitted  to  school,  however,  after  a  period  of  three  months,  even 
though  some  cough  remains. 

The  sputum  and  vomitus  should  be  carefully  removed  and  disinfected 
with  a  3  per  cent,  solution  of  lysol.  Since  the  organisms  die  very  rapidly 
outside  the  body,  disinfection  of  the  patient 's  room  is  unnecessary. 

According  to  a  large  number  of  workers,  pertussis  vaccine  is  definitely 
effective,  as  a  prophylactic  measure,  if  the  following  requirements  are  met. 
First,  the  use  of  a  freshly  prepared  vaccine  and  second,  the  administration  of 
of  sufficiently  large  doses.  The  following  four  doses  are  recommended  at 
forty-eight  hour  intervals;  one-half  billion,  one  billion,  two  and  one-half 
billions  and  five  billions. 

Treatment. — As  long  as  there  was  no  specific  therapy,  hygienic  measures 
were  the  mainstay  of  treatment.  The  most  important  of  these  is  fresh  air. 
Patients  without  fever  should  be  kept  in  the  open  as  much  as  possible. 
Older  children  may  be  permitted  to  play  about  in  the  garden,  in  the  woods, 
or  in  other  places  that  are  free  from  dust.  Smaller  children  should  be 
wheeled  or  carried  about.  In  the  open  air  the  paroxysms  are  less  frequent 
and  less  violent.  During  rough  and  cold  weather,  however,  the  patient 
should  be  kept  in  the  house,  but  even  there,  all  possible  provision  for  fresh 
air  should  be  made.  In  artificially  heated  rooms  the  atmosphere  must  be 
kept  at  the  proper  degree  of  humidity.  The  patient  with  fever  must  be 
kept  in  bed,  although  in  pleasant  weather  he  may  be  placed  on  a  veranda 
or  in  the  garden. 

The  value  of  a  change  of  environment,  so  highly  recommended,  has 
been  greatly  over-estimated.  It  is  of  value  only  when  it  means  transfer  to 
a  more  genial  climate — that  is  to  a  warmer  one  in  winter  or  to  a  dust-free, 
woody  place  during  the  summer. 

In  the  selection  of  a  dietary  the  irritability  of  the  mucous  membranes 
must  be  taken  into  account.  Highly  spiced,  coarse  foods  should  be  avoided, 
since  they  may  provoke  paroxysms  of  coughing.  When  the  attacks  are 
followed  by  vomiting  it  is  well  to  give  a  small  amount  of  food  immediately 
after  a  paroxysm.  Semi-liquid  food  is  to  be  preferred. 

If  the  paroxysms  are  very  numerous  a  moist  pack,  tepid  at  first,  and 
later  at  room  temperature,  applied  to  the  chest  for  two  or  three  hours,  has 
a  quieting  affect  even  in  cases  in  which  there  are  no  bronchial  rales. 

The  number  of  the  medicinal  agents  recommended  in  pertussis  is  legion, 


682  TEXT-BOOK  OF  PEDIATRICS 

the  most  definite  indication  that  no  certain  remedy  has  been  found.  Cases 
are  so  extremely  variable  in  severity  that  the  influence  of  drug  therapy  is 
hard  to  estimate.  Nevertheless,  there  are  certain  remedies  which  have  an 
action  more  definite  than  that  which  rests  upon  mere  suggestion.  In  judg- 
ing the  results  obtained  by  medication,  one  must  not  forget  that  while  it  is 
very  difficult  to  influence  the  disease  at  the  onset  of  the  convulsive  stage, 
it  is  very  easy  to  obtain  results  at  the  close  of  this  period. 

In  recent  cases  quinine  is  often  given.  To  infants  0.05-0.1  gm.  (%-l }/> 
grs.),  of  the  hydrochlorate  may  be  given  three  times  a  day;  to  older  chil- 
dren 0.15-0.5  gm.  (2-73/2  grs.),  twice  a  day.  Young  children  take  the  choco- 
late tablets  containing  the  quinine  tannate  very  well.  In  later  childhood, 
the  quinine  may  be  given  in  gelatin  capsules.  Euquinine  may  be  substi- 
tuted if  the  child  refuses  other  salts  of  quinine  on  account  of  their  taste. 
Of  this  preparation  infants  may  be  given  0.1  gm.  (2  grs.),  two  or  three  times 
a  day,  and  older  children,  0.15-0.5  gm.  (3-8  grs.),  three  times  daily. 
Antipyrin  may  be  tried  in  doses  of  0.03  gm.  Q/>  gr.),  for  each  month  of  age; 
or  0.3  gm.  (5  grs.),  for  each  year  of  life.  These  doses  of  antipyrin  appear  to 
be  rather  large  and  if  administered  are  worthy  of  very  careful  supervision. 

The  value  of  pertussis  vaccine  in  the  treatment  of  the  disease  has 
been  fairly  well  established.  Its  absolute  harmlessness  and  the  disagree- 
able chronicity  of  the  illness  justify  its  use  especially  if  it  can  be  admin- 
istrated before  the  paroxysmal  stage  has  begun.  For  this  purpose  a  fresh 
vaccine  is  absolutely  essential  and  the  dose  should  be  at  least  as  large  as 
that  advised  under  prophylaxis  and  no  objection  can  be  raised  to  giving  a 
fifth  injection  of  ten  billion  organisms. 

If  no  results  are  obtained  from  this  treatment  after  eight  or  ten  days  use 
and  if  severe  paroxysms  continue,  it  may  be  well  to  employ  narcotics  which 
never  wholly  fail  of  benefit.  For  the  purpose  codein  and  the  bromides  are 
most  highly  recommended.  An  infant  in  the  latter  half  of  the  first  year 
may  receive  0.001  gm.  (^0  gr-)  °f  codein;  a  child  of  two  years,  0.002- 
0.003  gm.  (Ho-Ko  gr.)j  a  child  of  five,  0.005-0.006  gm.  (MVHo  gr.), 
each  three  times  daily.  These  doses  may  be  doubled  if  they  do  not 
have  the  desired  effect.  Of  the  bromide  preparations,  the  sodium  salt  is 
preferred  and  may  be  given,  in  aqueous  solution,  to  infants  in  doses  of  0.3- 
0.5-1.0  gm.  (5-8-15  grs.),  each  day,  and  to  older  children  in  doses  of  3 
gms.  (45  grs.).  Bromoform,  in  large  doses,  given  three  times  a  day,  is  also 
highly  recommended.  This  heavy  oily  liquid  must  be  kept  in  dark  bottles. 
The  dose  beginning  with  two  drops  for  each  year  of  age,  may  be  increased 
a  drop,  at  a  time  in  similar  progression.  Thus  a  child  of  two  and  a  half 
years  would  receive,  initially,  five  drops  three  times  a  day,  increased,  later, 
to  five  drops  four  times  a  day  and  finally  to  a  maximum  of  seven  drops  four 
times  daily.  Infants  may  be  given  two  to  four  drops,  three  or  four  times 
daily,  while  older  children  may  be  given  as  high  as  forty  drops  in  the  course 
of  a  day.  The  required  amount  of  the  remedy  is  carefully  dropped  into  a 
teaspoonful  of  syrup  or  sugar  water.  It  is  usually  efficacious,  but  it-  does 
not  act  rapidly.  On  account  of  the  great  liking  which  children  sometimes 
acquire  for  bromoform,  its  use  should  be  guarded.  They  have  been  known 


THE  ACUTE  INFECTIOUS  DISEASES  683 

to  drink  an  entire  bottleful  at  once,  with  resulting  fatal  poisoning.  The 
remedy  should  be  placed  in  the  hands  of  careful  parents  only  and  must  be 
kept  away  from  the  children.  Often  it  has  been  useful  when  other  medici- 
nal agents  have  failed.  The  child's  appetite  frequently  shows  marked 
improvement  in  ten  to  fourteen  days. 

In  very  severe  and  threatening  paroxysms  a  dose  of  morphin  may  be 
given.  With  proper  precautions  an  infant  may  be  given  one  milligram 
(3^60  gr.),  two  or  three  times  a  day,  and  children  of  two  to  four  years,  two 
or  three  milligrams  (Mo-Ho  gr.),  twice  a  day.  Large  doses  of  morphin 
given  subcutaneously  have  been  recommended  recently,  but  the  writer  has 
not  witnessed  any  favorable  result  from  their  use. 

In  severe  spasm  of  the  glottis  or  in  eclamptic  attacks  large  doses  of  the 
bromides  often  save  the  patient.  From  0.5-1.0  gm.  (8-15  grs.),  a  day, 
may  be  used  in  infancy. 

Of  innumerable  other  remedies,  belladonna,  which  sometimes  has  a 
very  distinct  influence  may  be  mentioned.  Probably  it  serves  its  purpose 
by  reducing  the  excess  of  secretion.  Doses  of  from  1-3  milligrams  (Mo-^d 
gr.)  of  the  extract  of  belladonna,  or  doses  of  0.05-0.2  milligram  (Kooo- 
^oo  gr.)  of  atropin  sulphate  may  be  used  in  infancy;  from  30-50  milli- 
grams (^2-1  gr.)  of  the  extract  or  from  0.3-1  milligram  (/^oo-/^o  gr.)  of 
the  atropin  with  older  children.  The  smaller  doses  should  be  given  at 
first,  and  the  appearance  of  dilated  pupils  or  of  an  erythema  of  the  skin 
should  be  accepted  as  indications  for  the  immediate  reduction  of  the  amount. 
It  is  well  to  combine  this  remedy  with  the  bromides.  If  the  secretion  is 
very  tenacious  the  croup  kettle  or  the  evaporation  of  the  ethereal  oils 
often  gives  relief.  In  very  severe  and  alarming  attacks  a  combination  of 
bromides  with  codein  and  atropin  is  frequently  effective. 

During  attacks  it  is  well  to  lift  small  or  weak  children  and  to  support 
the  head. 

It  is  extremely  important  that  complicating  conditions  of  spasmophilia 
should  receive  antispasmophilic  treatment,  by  way  of  a  scant  diet,  with 
but  little  milk,  the  use  of  the  calcium  salts  and  if  necessary,  phosphorus 
and  cod-liver  oil.  Temporary  underfeeding  seems  to  be  beneficial  in  strong 
non-spasmophilic  children  with  severe  paroxysms. 

When  eclamptic  attacks  are  alarming  and  persist  in  spite  of  treatment, 
lumbar  puncture  sometimes  gives  relief.  Transitory  narcosis  may  also  be 
useful.  In  extreme  cases  with  persisting  spasm  of  the  glottis  intubation 
may  be  tried. 

Bronchitis  and  broncho-pneumonia  are  treated  in  the  usual  manner 
(see  pages  370-377).  With  excessive  bronchial  secretion,  the  question  often 
arises  whether  expectorants  or  narcotics  should  be  used.  Cardiac  insuf- 
ficiency is  combated  with  caffein  and  camphor  (see  page  415). 

Guaiacol  preparations  are  useful  in  pulmonary  involvement  during  the 
stage  of  decline.  From  0.05-0.15  gm.  (1-3  grs.),  of  guaiacol  carbonate  may 
be  given  three  times  a  day. 

If  convalescence  is  delayed  and  fever  persists  for  any  length  of  time, 
arousing  a  suspicion  of  tuberculosis,  the  child  should  be  sent  to  the'country, 


684  TEXT-BOOK  OF  PEDIATRICS 

to  the  seashore  or  to  the  mountains  for  a  time.  Institutions  for  the  treat- 
ment of  pertussis,  located  in  the  suburbs  of  large  cities,  fill  an  actual  need 
and  may  save  many  a  child  in  indigent  circumstances,  who  might  other- 
wise succumb  to  chronic  bronchitis  or  tuberculosis. 

MUMPS;  EPIDEMIC  PAROTITIS 

Mumps  is  a  contagious  disease,  the  chief  symptom  of  which  is,  com- 
monly, an  acute  swelling  of  the  parotid  gland.  The  causative  organism  of 
this  disease,  a  malady  recognized  since  the  time  of  Hippocrates,  has  not 
been  discovered.  Primary  and  idiopathic  parotitis  occurs  sporadically 
and  in  epidemics  of  variable  spread.  The  latter  may  extend  over  entire 
localities  and  invade,  particularly,  schools,  institutions,  barracks,  etc. 
These  epidemics  usually  last  for  several  months.  Sometimes  they  are  re- 
markable for  their  special  intensity,  sometimes  for  the  prevalence  of  unilat- 
eral expressions  and,  again,  for  the  appearance  of  complicating  diarrhoeas. 

The  contagion  is  commonly  conveyed  directly  from  the  sick  to  the  well. 
According  to  the  writer 's  observations,  the  contagious  period  antedates  the 
appearance  of  the  typical  swelling  of  the  gland  by  one  or  two  days;  it  usually 
decreases  rapidly  in  intensity  during  convalescence,  although  it  may  persist 
for  weeks  after  healing.  The  spread  of  the  disease  is  favored  by  the  occur- 
rence of  numerous  light  ambulant  cases.  It  is  possible  of  indirect  spread 
through  the  medium  of  healthy  individuals  and  even  by  means  of  infected 
utensils,  etc.  It  is  commonly  supposed  that  the  germs  enter  the  mouth 
and  pass  from  thence  through  Stenson's  duct.  This  conception,  however, 
seems  doubtful  when  the  atypical  forms  and  the  vagrant  localizations  of 
the  disease  are  taken  into  account. 

The  predisposition  to  the  disease  is  general,  although  it  is  not  universal. 
Persons  between  five  and  fifteen  years  show  the  greatest  liability.  The 
infection  of  children  less  than  two  years  of  age  is  uncommon  and  cases  in 
infancy  are  exceptional.  A  few  instances  of  the  disease  have  been  reported 
among  infants  and  even  congenital  infections,  derived  from  the  affected 
mother,  have  been  described.  One  attack  gives  positive  immunity.  Second 
attacks,  however,  have  been  not  infrequently  reported  in  adults. 

The  pathologic  basis  of  the  disease,  as  determined  in  the  few  examina- 
tions made,  consists  in  edema  and  congestion  of  the  interstitial  tissue  of  the 
parotid  gland  and  the  surrounding  structures.  A  round  cell  infiltration 
may  be  added.  The  parenchyma  of  the  gland  is  not  directly  involved. 

Mumps  has  a  very  long  incubation  period,  averaging  two  and  a  half  to 
three  weeks,  so  that  an  epidemic  invading  a  family  often  lasts  a  long  time. 

Clinical  Picture. — After  the  incubation  period,  without  symptoms, 
light  prodromes  are  often  noticed,  continuing  for  twelve  to  thirty-six  hours. 
The  child  is  languid,  irritable,  without  appetite,  and  suffers  with  chills  and 
slight  fever.  Sweats,  epistaxis,  and  pain  and  roaring  in  the  ears  may  de- 
velop. The  swelling  of  the  parotid  gland  of  one  side  immediately  follows,  or 
appears  as  an  initial  symptom.  A  slight  thickening  is  first  noticed  in  the 
part  of  the  parotid  that  lies  directly  over  the  ramus  of  the  jaw.  This  swell- 
ing is  often  more  readily  discovered  in  a  view  of  the  full  face  than  it  is  by 


THE  ACUTE  INFECTIOUS  DISEASES 


685 


palpation.  It  is  especially  evident  upon  comparison  of  the  two  sides  of  the 
face.  The  tumor  has  a  doughy  quality,  about  which  no  sharp  borderline 
can  be  recognized.  Its  characteristic  location,  immediately  beneath  the 
lobe  of  the  ear  and  in  front  of  the  tragus,  indicates  that  the  parotid  gland  is 
involved.  In  the  majority  of  cases  there  is  no  sensitiveness  to  touch  and 
when  present,  it  is  slight.  It  is  actually  painful  only  in  exceptional  cases. 
The  skin  over  the  swelling  shows  no  change.  If  the  tumor  is  very  large,  the 
skin  may  become  glossy,  but  is  scarcely  even  reddened  or  warm.  The 
increase  of  the  swelling  is  observed  for  two  or  three  days.  It  fills  the  space 


FIG.  174. — Epidemic  parotitis.  The  swelling  fills  the  hollow 
between  the  ratnus  of  the  jaw  and  the  sternomastoid  and 
forces  the  lobe  of  the  ear  outward. 

between  the  mastoid  process  and  the  ramus  of  the  jaw  and  forces  the  lobe 
of  the  ear  outward  quite  characteristically  (Fig.  174).  The  peculiar  plump- 
ness of  the  cheek  has  made  the  disease  familiar  to  the  laity  and  has  caused 
various  popular  names  to  be  applied  to  it,  which  testify  to  the  general 
harmlessness  of  the  disease. 

The  tumor  may  become  very  marked  and  the  edema  may  extend  far 
beyond  the  parotid  gland  up  to  the  orbit  and  down  to  the  horizontal  por- 
tion of  the  lower  jaw.  The  patient  often  complains  of  the  tenseness  of  the 
cheek.  He  experiences  difficulty  in  opening  the  mouth  and  pain  on  masti- 
cation. The  pressure  upon  the  external  auditory  canal  may  cause  lanci- 
nating pains  in  the  ear  and  deafness.  The  swelling  remains  at  its  height 


686  TEXT-BOOK  OF  PEDIATRICS 

for  some  two  days,  after  which  it  goes  down  rapidly.  At  or  before  this 
climax,  the  parotid  gland  of  the  other  side  becomes  affected  with  the  accom- 
paniment of  another  rise  of  temperature. 

Occasionally,  the  other  salivary  glands  are  involved  simultaneously 
with  the  parotid.  They  are  affected,  at  times,  instead  of  the  parotid  and 
may  swell  to  large  size.  The  submaxillary  gland  is  much  more  commonly 
infected  than  the  sublingual  (Fig.  175).  If  the  submaxillary  and  sublin- 
gual  glands  alone  are  involved,  or  if  the  swelling  of  the  parotid  has  been 
slight  and  has  escaped  recognition,  the  diagnosis  is  almost  impossible  unless, 
indeed,  the  case  occurs  during  an  epidemic. 

The  mucous  membrane  of  the  throat  and  mouth  are  often  slightly  red- 
dened. A  more  marked  degree  of  inflammation  in  the  form  of  a  catarrhal 


FIG.  175. — Simultaneous  illness  of  brother  and  sister  with  mumps  of  the  submaxillary  gland. 

or  lacunar  tonsillitis  is  rare.  The  saliva  flowing  from  the  parotid  duct 
shows  no  change  in  quality  but  is  sometimes  increased  in  quantity. 

The  accompanying  fever  shows  no  characteristic  features.  With,  or 
even  before,  the  initial  swelling  of  the  glands  the  temperature  usually  rises 
for  two  or  three  days.  It  commonly  varies  between  38°  and  39°  C.  (100°- 
102°  F.).  With  the  subsidence  of  the  swelling,  or  even  earlier,  it  falls 
rapidly,  but  no  characteristic  curve  can  be  determined.  Fever  above  39°- 
40°  C.  (102°-104°  F.)  is  rare  in  children,  but  not  necessarily  so  in  adults. 
The  fever,  sometimes,  is  of  so  brief  duration  and  so  insignificant  as  to 
escape  notice. 

The  course  of  the  disease. covers  five  to  seven  days  when  one  gland  is 
involved,  and  ten  to  twelve  days  when  both  sides  are  diseased.  The  attack 
almost  always  terminates  in  complete  recovery.  Very  exceptionally,  in 
cachectic  cases,  a  secondary  infection  causes  a  further  enlargement  of  the 
gland.  Relapses  after  a  period  of  ten  to  twenty  days  are  very  rare. 

The  disease,  with  extremely  few  exceptions,  takes  the  described  course 
without  serious  symptoms  and  without  leaving  any  permanent  injury.  As 


THE  ACUTE  INFECTIOUS  DISEASES  687 

a  rule,  the  malady  is  a  light  one  in  children  under  ten  years  of  age,  so  that  it 
is  hard  to  keep  them  indoors  and  but  few  cases  are  seen  by  the  physician. 

There  are  rare  cases,  however,  of  atypical  localization  and  very  occa- 
sionally with  severe  complications.  The  localization  of  the  disease  in  the 
testes  was  recognized  as  a  peculiar  feature  by  Hippocrates.  This  accident 
is  confined  almost  exclusively  to  youths  and  adults,  in  whom  it  occurs  in 
perhaps  one-third  of  the  cases.  Usually  about  a  week  after  the  onset  of 
the  parotitis  and  with  the  disappearance  of  the  swelling  in  the  cheeks, 
a  high  fever,  attended  at  tunes  by  delirium  and  with  serious  general 
disturbance,  sets  in.  Coincidentally  a  painful,  inflammatory  swelling  of 
one  or  both  testes  is  observed.  After  this  interstitial  inflammation  has 
subsided,  an  atrophy  of  the  testes  may  develop,  which,  if  both  sides  are 
affected,  causes  sterility.  In  children  such  an  orchitis  is  exceedingly  rare. 
It  occurs  only  after  the  thirteenth  year  and  very  seldom  in  advance  of  the 
development  of  the  sexual  function.  Sometimes  it  appears  before  the  paro- 
titis and  may  even  be  the  only  local  expression  of  the  disease.  An  analogous 
inflammation  of  the  ovaries  and  the  mammary  gland  is  said  to  occur  in 
females.  The  occasional  syndrome  of  vomiting,  abdominal  pains  and  tender- 
ness upon  pressure  in  the  region  of  the  pancreas  has  been  taken  as  evi- 
dence of  pancreatitis. 

In  common  with  other  infectious  diseases,  mumps  is  now  and  then  fol- 
lowed by  nephritis.  This  is  usually  of  a  hemorrhagic  and  transitory  type. 
As  exceptional  symptoms  may  be  noted  a  swelling  of  the  thyroid,  of  the 
lachrymal  gland  or  of  individual  joints,  and  variant  eyrthemata,  sometimes 
of  a  rubeolar  and  again  of  an  urticarial  character. 

The  nervous  system  is  materially  affected  in  but  very  few  cases.  Cer- 
tain French  authors  state  that  the  development  of  a  slight  serous  meningitis 
is  not  rare.  Its  manifestations,  of  somewhat  indefinite  order,  are  fever, 
headache  and  a  slow  pulse.  The  cerebrospinal  fluid  is  said  to  show  the 
objective  evidence  of  these  indistinct  symptoms  in  an  increase  of  its  protein 
content  and  its  lymphocytes.  Within  a  few  days  these  conditions  disappear. 
Very  rarely  they  go  on  to  the  development  of  a  well-marked  form  of  menin- 
gitis, still  of  a  serous  type,  evidenced  by  rigidity  of  the  neck,  Kernig  's  sign, 
delirium  and  convulsions,  and  even  leading  on  to  death  The  occasional 
appearance  of  paralyses  of  the  ocular  muscles  or  of  monoplegia  show  that 
meningoencephalitic  changes  may  occur,  while  polyneuritic  paralyses  sug- 
gest that  the  peripheral  nervous  mechanism  is  not  always  spared.  A  sudden 
acute  labyrinthitis,  causing  deafness  upon  the  affected  side  or  even  com- 
plete deafness  if  both  ears  are  affected,  has  been  known,  but  fortunately  is 
extremely  rare.  A  harmless  otitis  media  is  more  common.  A  transitory 
facial  paralysis  may  be  due  to  compression  of  the  nerve  branches  by  the 
swelling  of  the  parotid  gland.  Acute  mental  confusion  and  rapidly  passing 
psychoses  are  occasionally  described. 

The  diagnosis  of  epidemic  parotitis  is  ordinarily  easy  and  is  often  made 
by  the  laity  merely  from  the  typical  swelling  of  the  cheeks.  Its  epidemic 
occurrence  and  the  sequence  of  its  development  first  on  one  side  of  the  face 
and  then  the  other  side,  is  of  assistance  in  doubtful  cases.  The  disease  is 


688  TEXT-BOOK  OF  PEDIATRICS 

most  likely  to  be  confused  with  lymphadenitis  or  with  alveolar  periostitis. 
Mumps,  however,  gives  a  doughy  non-circumscribed  swelling  in  front  of 
the  tragus,  where  enlargement  of  the  lymph  nodes  is  uncommon.  The 
well-rounded  extension  downward  of  the  primary  swelling,  but  without  red- 
ness or  pain,  is  typical  of  mumps.  In  lymphadenitis  the  swollen  node  can 
be  easily  palpated  and  its  phlegmonous  painful  character  is  quite  clear. 
Metastatic  parotitis  appears  among  the  complications  of  severe  infectious 
disease,  as  in  diphtheria,  typhoid  fever,  etc.,  and  is  seldom  an  occasion  for 
error.  Moreover,  it  always  tends  to  suppurate.  Isolated  instances  of 
mumps  of  the  submaxillary  glands  or  of  the  testes  are  discovered  only  in 
the  midst  of  epidemics.  Finally,  it  may  be  noted  that  some  persons  react 
to  iodin  medication  with  a  fluctuating  swelling  of  the  parotid. 

Prognosis. — It  is  apparent  from  the  related  history  that  the  prognosis 
is  not  always  as  favorable  as  it  is  generally  believed  to  be,  even  though  these 
serious  complications  are  rare.  The  prognosis  is  alwaysbetter  in  children  than 
in  adults,  so  that  it  may  appear  to  be  a  mistake  to  protect  healthy  children 
from  the  disease.  Still,  considering  the  possibility  of  permaneritdeafness  it  is 
doubtless  the  part  of  wisdom  to  guard  the  child  carefully  from  infection. 

The  treatment  may  be  expectant  and  confined  to  rest  in  bed  and  to 
liquid  diet  during  the  febrile  stage.  The  swelling  may  be  covered  with 
warm  oil  or  with  bland  ointment  and  be  protected  with  dry  cotton.  For 
the  care  of  the  mouth  and  for  accompanying  angina,  irrigation  and  gargling 
with  solutions  of  borax  are  recommended.  It  is  well  to  consider  the  secre- 
tions of  the  mouth  as  contagious  and  to  render  them  harmless  by  disinfec- 
tion; as  it  is,  also,  to  prevent  the  spread  of  the  disease  by  avoiding  kissing 
the  patient,  etc.  In  hospitals,  institutions,  etc.,  it  may  be  necessary  to 
fumigate  the  place,  after  the  infected  inhabitants  have  been  removed,  in 
order  to  bring  the  epidemic  to  an  end. 

TYPHOID  FEVER 

Typhoid  fever  is  a  specific  acute  infectious  disease,  in  which  the  intesti- 
nal tract  and  its  lymphoid  system  are  especially  affected,  the  clinical  pic- 
ture of  which  is  largely  dominated  by  the  general  symptoms. 

The  causative  organism  is  the  bacillus  typhosus,  an  organism  closely 
related  to  the  colon  group.  It  may  be  demonstrated,  almost  always,  in  the 
blood  and  in  the  invaded  organs  of  the  infected  subject  from  the  beginning 
of  the  febrile  period.  It  is  found  in  thirty  per  cent,  of  the  fecal  specimens 
and  in  fifty  per  cent,  of  the  urinary  specimens  of  patients  up  to  a  late  stage 
of  convalescence.  Healthy  typhoid  carriers  are  found  among  children, 
although  they  are  much  less  common  than  among  adults.  This  relative 
scarcity  is  probably  due  to  the  fact  that  disease  of  the  gall-bladder,  which 
favors  the  continued  growth  of  the  micro-organism  for  a  long  time  after 
the  subsidence  of  the  disease,  is  infrequent  in  the  young. 

Direct  transmission  of  the  disease  is  more  common  than  was  formerly 
supposed.  The  lack  of  cleanliness  in  small  children  favors  the  infection  of 
attendants  or  of  persons  living  in  the  same  house.  Typhoid  fever  in  infants, 
usually  a  matter  of  late  diagnosis,  is  especially  dangerous  hi  this  respect,  as 


THE  ACUTE  INFECTIOUS  DISEASES  689 

the  writer 's  experience  in  several  cases  has  shown.  Almost  without  excep- 
tion the  infection  is  brought  about  by  bacilli  which  escape  in  the  feces  and 
urine  and  which,  failing  of  destruction,  contaminate  drinking  water,  milk, 
or  other  food  materials.  In  this  way  large  epidemics  arise  through  the  use 
of  infected  water  supplies,  milk,  etc.  The  food  probably  serves  only  as 
means  of  entry.  Cases  in  which  the  infant,  fed  at  the  breast  of  a  mother 
with  typhoid  fever,  is  infected  are  doubtless  traceable  to  a  lack  of  cleanli- 
ness upon  the  part  of  the  mother  in  the  care  of  pacifiers,  bathing  materials, 
etc.,  rather  than  to  the  passage  of  bacteria  through  the  mammary  gland. 
Many  cases,  indeed,  have  been  observed  in  which  the  children  of  mothers 
suffering  with  typhoid  have  not  been  infected. 

Typhoid  fever  often  occurs  in  several  members  of  a  family  who  come  down 
with  the  disease  in  rapid  succession.  Thanks  to  the  advances  of  public 
hygiene,  large  epidemics  have  become  infrequent  in  late  years. 

Predisposition  in  the  child  is  practically  the  same  as  in  the  adult  after 
the  fifth  year.  In  children  of  two  to  five  years  it  is  decidedly  less,  while 
infants  are  but  rarely  attacked  and  cases  within  the  first  six  months  are 
exceptional.  No  doubt  cases  of  light  and  atypical  form  may  occur  during 
the  first  year  and  escape  diagnosis.  This  very  fact  may  give  the  opportun- 
ity for  some  epidemics.  A  few  definite  cases  of  congenital  typhoid  fever, 
with  the  disease  present  in  the  mother,  in  which  the  typhoid  bacillus  had 
passed  through  the  placenta  have  been  reported.  Typhoid  in  the  mother 
during  pregnancy  usually  causes  the  abortion  and  death  of  the  fetus.  The 
child  proves  viable  in  but  very  few  instances. 

Predisposition  to  typhoid  seems  to  be  quite  general.  The  question  is 
determined  rather  by  the  virulence  of  the  infection  than  by  the  individual 
resistance.  In  localities  where  typhoid  is  endemic  new  arrivals  usually 
take  the  disease  more  readily  than  old  inhabitants,  even  though  the  latter 
have  never  had  the  disease.  It  is  doubtful  whether  one  attack  of  typhoid 
confers  an  immunity  which  lasts  for  any  considerable  period.  Second 
attacks  are  not  uncommon. 

Pathologic  Anatomy. — Pathologic  study,  as  well  as  clinical  signs,  go  to 
show  that  the  typhoid  processes  in  the  child's  intestine  are,  generally  speak- 
ing, more  superficial  and  less  serious  than  in  the  adult.  In  cases  within  the 
first  year,  both  the  agminated  and  the  solitary  nodes  usually  show  only 
moderate  swelling  and  small  discrete  patches  which  heal  quite  rapidly. 
The  large,  deep-seated  patches  frequently  found  in  the  adult,  in  whom  they 
tend  to  extensive  ulceration  and  even  to  perforation,  are  observed  in  child- 
hood only  after  the  seventh  or  eighth  year,  and  even  then  are  less  common 
than  in  the  adult.  Swelling  of  the  mesenteric  lymph  nodes  is  occasionally 
very  marked  even  in  the  infant,  but  similar  enlargement  may  occur  in 
numerous  other  intestinal  infections. 

The  clinical  picture  of  typhoid  fever  in  childhood  is  generally  that  of  a 
mild  type,  frequently  termed  gastric  fever  in  the  past,  a  quality  which  is 
the  more  pronounced,  the  younger  the  child.  Shorter  periods  of  fever, 
lower  temperature,  abortive  forms,  less  prominent  nervous  symptoms, 
and  a  rarity  of  intestinal  hemorrhage,  are  typical  of  the  typhoid  of  childhood. 
44 


690 


TEXT-BOOK  OF  PEDIATRICS 


The  typical  form  of  typhoid  fever  in  childhood  presents  a  well-marked 
clinical  picture.  The  patient  suffers  at  first  with  indefinite  symptoms,  the 
time  of  onset  of  which  it  is  difficult  to  determine.  These  prodromes  consist 
of  lassitude,  diminished  appetite,  vomiting,  restless  sleep  and,  in  older 
children,  headache.  In  spite  of  a  high  temperature,  which  is  not  hi  accord 
with  the  slightly  disturbed  health,  it  is  often  impossible  for  some  days  to 
determine  the  existence  of  any  organic  disease. 

In  many  cases  the  fever  is  the  most  important  symptom  of  the  disease. 
This  commonly  shows  the  classical  curve ;  a  step-like  rise,  a  stage  of  contin- 
ued high  fever,  and  then  a  period  of  marked  variations.  In  the  child  these 
several  stages  are  often  shorter  than  they  are  in  the  adult.  The  temper- 
ature reaches  its  maximum  after  four  or  five  days,  the  extreme  peak  of  the 
curve  is  maintained  for  about  one  week,  and  in  the  ensuing  three  to  five 
days  great  variations  of  fever  are  observed.  The  entire  febrile  period  is 
often  completed  in  two  weeks  (Fig.  176).  The  stepladder  rise  of  the  fever 
is  often  absent  in  the  child.  A  high  temperature,  sometimes  preceded  by  a 


FIG.  176. — Typhoid  fever  in  infant  of  seven  months. 


chill,  may  be  seen  in  older  children  on  the  first  day  of  actual  illness.  This 
onset,  however  is  only  apparently  acute.  It  merely  means  that  in  strong, 
robust  children  the  initial  symptoms  are  overlooked,  sometimes  for  want 
of  careful  observation  on  the  part  of  the  parent.  In  children  of  less  than 
five  years  the  temperature  during  the  stage  of  continued  fever  is  usually 
not  above  39.5°-  40°  C.  (103°-104°  F.),  but  in  later  childhood  it  may  run 
higher  even  in  ordinary  cases.  The  range  of  morning  and  evening  temper- 
ature is  between  0.5°  and  1.2°  C.  (1°  to  2.°  F.).  The  fever  is  of  a  remittent 
character  in  children  more  frequently  than  it  is  in  adults,  so  that  a  clas- 
sical curve  cannot  always  be  expected. 

The  clinical  diagnosis  usually  remains  doubtful  throughout  the  entire 
first  week.  The  probability  of  typhoid  becomes  greater  with  each  day  of 
persisting  or  increasing  temperature,  for  which  no  organic  cause  is  to  be 
found.  Frequent  vomiting,  a  thickly  coated  tongue,  the  moderate  redden- 
ing of  the  throat  and  headache  are  symptoms  too  common  to  justify,  in 
themselves,  a  diagnosis. 

The  tongue  is  usually  thickly  coated  and  dry.  In  older  children  it  is 
often  clean  around  the  edges  and  at  the  tip,  where  the  clean  area  has  a 
triangular  form.  The  coating  and  dryness  are  scarcely  ever  as  marked  as  in 


THE  ACUTE  INFECTIOUS  DISEASES  691 

the  adult.  Discolored  sordes  are  seen  only  in  severe  cases.  Frequently  the 
lips  become  dry  and  cracked,  leading  the  patient  to  pick  at  them. 

The  enlarged  spleen  is  usually  palpable  at  the  end  of  the  first  or  the 
beginning  of  the  second  week.  It  is  of  diagnostic  value  only  when  the 
enlargement  is  marked  and  develops  rapidly.  Even  then,  allowance  must 
be  made  for  the  fact  that  in  children,  an  increase  in  the  size  of  the  spleen 
occurs  in  very  many  infections.  If  the  routine  examination  is  not  embar- 
rassed by  meteorism,  the  enlargement  of  the  spleen  is  hardly  to  be  missed 
during  the  second  week  of  the  disease. 

Rose  spots  commonly  appear  at  the  beginning  of  the  second  week  and 
often  they  are  very  few  in  number,  so  that  the  surface  of  the  abdomen,  etc., 
must  be  searched  for  them.  In  young  children  they  are  not  infrequently 
absent  throughout  the  entire  course. 

Meteorism,  as  a  rule,  is  very  slight  in  children,  but  they  complain  of  ab- 
dominal tenderness  comparatively  often.  This  pain  is  increased  on  pressure 
over  the  region  of  the  appendix,  but  there  is  no  sense  of  muscular  resistance. 

The  bowel  movements  are  usually  normal  or  constipated  during  the 
first  week.  In  the  young  child  an  early  tendency  to  diarrhoea  is  not  uncom- 
mon. After  the  first  week  the  stools  are  generally  watery  and  very  often 
have  the  well-known  pea  soup  consistency.  There  are  seldom  more  than 
four  to  six  bowel  movements  in  the  course  of  the  day.  In  a  large  proportion 
of  cases,  possibly  in  from  one-fifth  to  one-third  of  them,  normal  stools  are 
passed  throughout  the  illness.  This  has  been  observed  even  in  patients  in 
whom  intestinal  hemorrhage  occurs  later. 

In  many  cases  a  slight  bronchitis,  announced  by  a  cough,  develops.  It 
almost  always  appears  in  feeble  children  and  in  those  who  fail  of  proper 
care.  In  severe  cases  of  long  duration  it  may  lead  to  broncho-pneumonia. 
Rickitic  children  and  those  who  suffer  disturbances  of  nutrition  are  espe- 
cially liable  to  this  disease.  Broncho-pneumonia  is  the  most  common  cause 
of  death  in  the  typhoid  of  childhood. 

The  heart  usually  shows  no  distinct  changes.  Its  integrity  and  great 
power  of  resistance  during  childhood  contribute  largely  to  a  favorable  ter- 
mination. The  slowness  of  the  pulse  relatively  to  the  temperature  rise,  an 
important  indication  in  the  typhoid  adult,  is  distinctly  evident  in  children 
only  after  the  sixth  to  the  eighth  year.  The  same  age  factor  affects  the 
development  of  a  dicrotic  pulse. 

In  non-complicated  typhoid  cases,  the  blood  shows  a  distinct  leucopenia, 
•a  reduction  of  the  neutrophiles,  and  a  disappearance  of  the  eosinophiles. 
Later  the  lymphocytes  often  exceed  the  leucocytes.  During  the  period  of 
high  fever  the  urine  contains  traces  of  albumen  and  a  few  casts.  Distinct 
nephritis  rarely  occurs.  Pyelitis  is  more  common.  In  very  nearly  every 
case  attended  by  marked  fever,  a  strong  diazo-reaction  is  present  from  the 
end  of  the  first  week  and  persists  throughout  the  stage  of  high  temperature. 

The  nervous  system  is  but  slightly  affected  in  young  subjects  if  the  fever  is 
not  too  intense  and  does  not  continue  for  too  long  a  time.  Headache,  rest- 
lessness, apathy  and,  more  rarely,  a  moderate  or  noisy  delirium,  occur  in 
ordinary  cases  and  particularly  in  those  who  are  not  given  required  treatment. 


692  TEXT-BOOK  OF  PEDIATRICS 

The  entire  febrile  disease  often  lasts  for  only  one  and  a  half  to  three 
weeks.  After  the  third  or  fourth  week  children  are  commonly  convalescent 
and  even  from  a  severe  attack  recuperate  with  surprising  rapidity. 

A  rarer  and  distinctly  more  serious  type,  however,  stands  in  sharp  con- 
trast to  this  essentially  mild  form  of  the  disease.  It  is  seen  with  greatest 
frequency  in  later  childhood  i.  e.,  in  children  over  five  years  of  age  and 
chiefh'-  in  the  course  of  prevalent  epidemics.  It  resembles  the  graver  forms 
of  typhoid  fever  in  the  adult.  Long  continued  high  fever,  running  up  to 
40°  C.  (104°  F.),  or  more;  a  violent  and  excited  delirium,  persistent  head- 
ache, deafness,  and  hyperesthesia  of  the  skin  over  the  abdomen,  are  its 
principal  early  features.  Oftentimes  at  the  beginning  there  is  a  condition 
of  profound  apathy,  which  may  deepen  into  somnolence  and  coma.  Food 
is  refused;  the  tongue  becomes  dry  and  covered  with  sorcles;  the  pulse  is 
small  and  very  slow.  Within  a  few  days  bronchitis,  attended  by  cough, 
makes  its  appearance  and  may  lead  in  turn  to  extensive  broncho-pneumo- 
nia. Diarrhoea  aggravates  the  increasing  exhaustion.  Intestinal  hemor- 
rhages are  not  uncommon.  Deep-seated  ulcers  may  cause  perforation. 
Evidences  of  meningism,  and  particularly  Kernig's  sign,  rigidity  of  the 
neck,  hyperesthesia  of  the  skin  and  spasm  of  the  jaw  muscles,  occur  more 
frequently  than  in  adults. 

PECULIARITIES  OF  COURSE;  COMPLICATIONS 

While  in  the  young  the  course  of  typhoid  fever  resembles  that  in  the 
adult  more  and  more  closely  as  the  years  advance,  the  picture  in  infancy  is 
oftentimes  not  a  very  characteristic  one  and  frequently  remains  unrecog- 
nized. Even  in  cases  that  prove  fatal  the  intestinal  lymph  nodes  are  but 
slightly  involved.  On  this  account  the  familiar  findings  are  often  missed 
at  autopsy  and  the  disease  is  essentially  an  acute  septicemia.  The  course 
is  commonly  short,  the  fever  remains  moderate  and  lacks  the  features  of 
the  typical  curve  (Fig.  177).  The  accompanying  vomiting,  diarrhoea,  mete- 
orism  and  coated  tongue  give  occasion  for  a  diagnosis  of  gastro-enteritis. 
Notwithstanding  the  persistent  fever,  the  absence  of  colitic  stools  and  the 
early  palpable  enlarged  spleen  should  arouse  suspicion  of  the  true  character 
of  the  disease.  In  the  majority  of  cases  a  few  rose  spots  also  appear.  The 
tendency  to  apathy,  rigidity  of  the  neck,  and  the  tensity  of  the  fontanelle 
often  suggest  a  meningitic  character.  Frequently  a  correct  diagnosis  is 
dependent  upon  the  presence  of  other  cases  in  the  neighborhood.  Typhoid 
fever  occurring  in  infants  and  in  children  of  two  or  three  years  is  frequently 
transmitted  to  the  attendants  or  to  other  persons  in  the  home,  a  circum- 
stance explained,  in  part,  by  an  often  late  diagnosis  and,  in  part  also,  by  a 
lack  of  cleanliness  in  the  habits  of  these  small  patients.  The  writer  agrees 
with  the  contention  of  Fischl  that  the  prognosis  of  typhoid  fever  in  infancy 
is  not  bad. 

The  Digestive  System. — Typhoid  sometimes  begins  with  a  catarrhal  or 
lacunar  angina.  In  a  few  instances  a  thin  veil-like  exudate  is  seen  on  the 
tonsils.  In  severe  cases,  when  the  mouth  is  not  properly  cleansed,  aphtha- 
like  ulcers  may  develop  and  cheesy  exudates  appear  on  the  gums.  Occa- 


FIG.  177. — Severe  typ 


ever  in  six-year-old  girl. 


THE  ACUTE  INFECTIOUS  DISEASES  693 

sionally  thrush  is  seen.  A  secondary  infection  of  the  parotid  gland,  leading 
to  suppuration,  may  ensue.  In  neuropathic  patients  the  vomiting  may 
continue  for  days,  while  in  others  it  occurs  only  at  the  onset.  In  serious 
and  often  fatal  forms,  a  marked  swelling  of  the  liver  may  be  evident.  A 
long  continued  infection  of  the  bile  ducts,  a  cholecystitis,  or  a  peritonitic 
exudate  is  very  exceptionally  seen  and  only  in  late  childhood. 

The  Respiratory  Tract. — The  nose  is  usually  dry,  and  this  leads  the 
child  to  do  injury  to  the  mucous  membrane.  Epistaxis  is  rather  common 
in  older  children,  but  it  requires  no  treatment. 

Otitis  media  accompanies  the  disease  more  often  in  childhood  than  in 
adult  years.  It  often  leads  to  a  benign  suppuration  which  does  not  partic- 
ularly affect  the  course  of  the  disease.  Young  children  with  severe  bron- 
chitis tend  especially  to  this  complication.  Marked  laryngitis  with  necrosis 
of  the  cartilages  is  rare. 

Broncho-pneumonia  hardly  ever  develops  before  the  second  week.  Fre- 
quently it  begins  without  any  distinct  symptoms  in  the  hypostatic  para- 
vertebral  form.  It  may  extend  to  other  large  areas  very  rapidly.  A  rare, 
but  serious  complication  is  the  appearance  of  an  exudative  pleurisy  which 
often  becomes  purulent. 

The  heart  suffers  to  a  great  extent  only  in  severe  cases  of  long  duration. 
Heart  failure  is  much  more  uncommon. than  in  adults  and  sudden  unlooked- 
for  cardiac  death  is  still  less  frequent.  Toxic  myocarditis  often  manifests 
itself  in  diminished  clearness  of  the  first  sound  of  the  heart,  in  marked 
tachycardia  and,  at  times,  even  in  systolic  murmurs  and  enlargement  of 
the  heart.  Bradycardia  and  irregularity  during  convalescence  have  no 
serious  significance.  Endo-  and  pericarditis  are  comparatively  rare. 

The  function  of  the  kidneys  is  very  seldom  disturbed  to  any  serious 
degree.  Even  in  severe  cases  distinct  nephritis  is  rare.  It  seldom  becomes 
a  prominent  feature  in  the  disease-picture  and  almost  always  disappear 
when  convalescence  sets  in.  It  is  a  remarkable  fact  that  children  who  have 
acquired  habits  of  cleanliness  hardly  ever  lose  control  of  the  bowels  and 
bladder  even  thougli  they  may  be  very  ill.  Even  without  the  development 
of  albuminuria,  typhoid  bacilli  are  occasionally  demonstrable  in  the  urine 
up  to  the  period  of  convalescence.  The  diazo-reaction  reappears  in  the 
event  of  relapse,  but  not  in  such  febrile  complications  as  broncho-pneumonia. 
The  Nervous  System. — In  late  childhood  aphasia  is  now  and  then  ob- 
served and  may  be  independent  of  apathy  or  stupor.  During  convalescence 
a  transitory  mental  disturbance  or  depression  may  be  noted.  In  severe  cases, 
some  degree  of  paresis  of  the  extremities  and  particularly  of  the  legs  is 
occasionally  recorded.  Meningitic  symptoms  are  more  common  with  chil- 
dren than  with  adults.  They  may  be  significant  of  a  serous  meningitis  as  a 
phase  of  typhoid  infection,  a  diagnosis  supported  by  the  increased  pressure 
of  the  cerebrospinal  fluid  which  contains  an  increased  number  of  lymph- 
ocytes. From  a  prognostic  standpoint,  these  symptoms  are  unfavorable. 
The  Skin. — At  the  onset  of  the  disease  toxic  erythemata,  commonly  of 
a  scarlatinal  type,  are  not  uncommon,  or  are  at  least  decidedly  more  com- 
mon than  in  the  adult.  In  the  later  stages  of  the  severer  grades  of  infection, 


694  TEXT-BOOK  OF  PEDIATRICS 

polymorphous  erythemata  will  sometimes  appear.  Dark  red  cheeks  and 
cyanotic  mottled  extremities  are  unpleasant  indications  and  evidence  paral- 
ysis of  the  vasomotor  system.  After  the  fever  has  subsided  profuse  sweats 
and  the  consequent  formation  of  sudamina  are  frequent.  Later,  extensive 
desquamation  of  the  skin  of  the  trunk  and  limbs  is  often  seen.  The  surface 
of  the  face  and  of  the  hands  and  feet  is  not  affected.  Decubitus  is  much 
less  common  than  in  adults.  During  convalescence,  it  is  not  unusual  to 
find,  even  in  mild  cases,  multiple  skin  abscesses.  These  are  especially  com- 
mon in  certain  epidemics. 

The  Osseous  System. — In  contrast  to  the  slight  liability  of  the  adult 
the  skeleton  is  very  often  affected  in  typhoid  children.  During  convales- 
cence, and  sometimes  within  a  subsequent  period  of  three  to  six  months, 
small  circumscribed  periostitic  foci  are  occasionally  found.  The  most  fre- 
quent seat  of  these  is  on  the  tibia.  As  a  rule  they  do  not  cause  fever.  Upon 
incision  pus  containing  typhoid  bacilli  is  drained  from  these  areas.  A 
thickening  of  the  periosteum  remains  after  healing.  Larger  areas  of  osteo- 
myelitic  infection  are  uncommon. 

At  times,  the  convalescent  from  typhoid  exhibits  a  rapid  gain  in  height. 
In  the  young  this  growth  may  be  so  marked  as  to  cause  transverse  separa- 
tions of  the  cutis,  similar  to  the  linea  albicantes  of  pregnancy,  on  the  exten- 
sor surface  of  the  thighs 

Recurrences  of  the  disease  are  rather  common  and  seem  to  depend  more 
upon  the  character  of  the  epidemic  than  upon  external  conditions.  As  in 
the  adult,  they  usually  appear  from  three  to  ten  days  after  the  subsidence 
of  the  first  febrile  period. 

Diagnosis. — As  the  foregoing  history  suggests,  the  diagnosis  of  typhoid 
fever  in  children  is  beset  with  greater  difficulties  than  it  is  in  later  life.  It 
is  oftener  impossible  to  make  the  diagnosis  from  the  clinical  data  alone. 

A  severe  febrile  disturbance  lasting  for  several  days  or  weeks,  without 
any  demonstrable  local  cause,  presents  always  the  probability  of  typhoid 
fever.  Other  obscure  organic  diseases  must  be  excluded  by  repeated  care- 
ful examinations.  Into  this  differentiation  come,  among  other  possibilities, 
cystitis,  certain  forms  of  acute  rheumatism,  the  gastro-intestinal  form  of 
influenza,  and  lobar  pneumonia.  There  are  central  pneumonias  which  do 
not  produce  distinct  pulmonary  symptoms  for  perhaps  two  weeks.  Rapid 
respiration,  with  wide  expansion  of  the  alse  nasi,  suggests  pneumonia.  The 
Roentgenogram  shows  a  shadow  at  the  apex  or  at  the  hilus.  A  marked 
swelling  of  the  spleen  indicates  typhoid.  The  differentiation  from  appendi- 
citis occasionally  causes  some  difficulty.  Cases  of  typhoid  occur  in  which 
vomiting  and  pain,  localized  in  the  region  of  the  appendix,  persist  for  days. 
On  the  other  hand,  cases  of  peri-appendicitis  are  seen  in  which  the  local 
inflammation  and  tenderness  are  subordinate  and  the  fever  is  the  most 
prominent  symptom  for  some  time.  In  these  instances  the  discovery  of  a 
leucopenia  points  to  typhoid.  An  ordinary  gastro-enteritis  cannot  simulate 
typhoid  for  more  than  a  few  days,  since  its  initial  accompaniment  of  fever 
does  not  persist.  Miliary  tuberculosis,  so  common  a  disease  in  childhood, 
causes  much  diagnostic  difficulty  for  some  time,  and  this  is  equally  true  of 


THE  ACUTE  INFECTIOUS  DISEASES  695 

that  form  which  is  confined  to  the  meninges.  Either  type  commonly  begins 
with  fever,  which  continues  for  a  week  or  two  before  pulmonary  or  cerebral 
symptoms  become  apparent.  Cryptogenic  sepsis,  and  ulcerative  endocar- 
ditis, in  particular,  is  less  often  a  matter  for  differential  diagnosis  among 
children  than  it  is  with  adults.  It  is  rare  in  that  period  of  childhood  when 
special  predisposition  to  typhoid  exists.  A  suspicion  of  purulent  or  cerebro- 
spinal  meningitis  may  disturb  the  diagnostician  for  a  very  short  time  in 
studying  the  most  severe  forms  of  typhoid. 

Apart  from  the  high  temperature,  the  most  important  diagnostic  points, 
in  the  absence  of  evidence  of  organic  disease,  are  the  splenic  enlargement, 
appearing  at  the  beginning  of  the  second  week,  and  the  presence  of  rose 
spots.  In  doubtful  cases  the  diazo-reaction  is  very  helpful  and  in  the  author 's 
judgment  is  very  much  underrated.  A  strong  diazo-reaction  is  present  in 
almost  every  case  of  typhoid  fever  from  the  beginning  of  the  first  week  and 
during  the  entire  period  of  high  temperature.  If  this  reaction  is  absent, 
typhoid  may  be  excluded  with  some  degree  of  certainty.  On  the  contrary, 
the  presence  of  the  reaction  is  by  no  means  positive  proof  of  typhoid,  since 
it  occurs  in  a  number  of  other  diseases  and  among  them  in  miliary  tubercu- 
losis, lobar  pneumonia,  etc.  In  these  diseases,  however,  it  is  rarely  as 
distinct  or  as  constant.  In  doubtful  cases  leucopenia  often  establishes  the 
diagnosis.  A  definite  diagnosis  is  often  impossible,  even  in  the  second  week, 
if  splenic  enlargement  and  rose  spots  are  lacking,  or  when  broncho-pneumo- 
nia is  the  most  marked  feature  in  the  clinical  picture.  At  this  point,  the 
laboratory  diagnosis  serves  to  clear  up  the  situation.  As  in  the  adult,  so  in 
the  child,  with  the  beginning  of  the  second  week,  the  blood  causes  the  agglu- 
tination of  typhoid  bacilli  in  fresh  culture.  The  agglutinative  power  of  the 
normal  blood  of  the  child  is  less  than  in  the  adult  blood  and  agglutination, 
therefore,  in  a  suspension  of  1:50  may  be  considered  positive  for  typhoid 
in  the  young. 

The  demonstration  of  the  typhoid  bacillus  in  the  blood,  usually  possible 
within  the  first  few  days  with  adults,  is  often  a  very  difficult  matter  in 
children,  since  the  required  volume  of  blood  can  be  obtained  usually  only 
by  venous  puncture  and  veins  suitable  for  this  purpose  are  hardly  ever 
available  in  children  under  five  years  of  age.  On  this  account,  greater 
reliance  must  be  placed  upon  the  agglutination  test  and  it  should  be  em- 
ployed in  all  doubtful  cases.  The  demonstration  of  the  bacilli  in  the  stools 
and  the  urine  is,  of  course,  reliable  proof,  but  the  organisms  are  not  always 
present  in  these  excreta. 

The  prognosis  is,  on  the  whole,  more  favorable  in  childhood  than  in 
adult  life,  but  it  depends  greatly  upon  the  violence  of  the  epidemic.  Menin- 
gism,  persistent  coma,  profuse  diarrhoea,  all  decrease  the  chances  of  recovery. 
In  most  instances  the  patient  convalesces  with  surprising  rapidity. 

Prophylaxis  is  the  same  at  all  ages.  Isolation  of  the  patient  is  desirable. 
Careful  removal  and  disinfection  of  the  bedclothing,  etc.,  apt  to  be  soiled 
with  urine  or  feces,  are  especially  important.  For  disinfection  the  linen 
may  be  placed  in  a  5  per  cent,  solution  of  lysol,  in  which  it  should  be  kept 
until  it  can  be  boiled.  The  nurse  should  wear  a  large  enveloping  apron  in 


696  TEXT-BOOK  OF  PEDIATRICS 

the  sick-room  and  must  wash  her  hands  scrupulously  after  touching  the 
patient  or  any  object  in  contact  with  him.  Upon  the  appearance  of  typhoid 
fever  in  a  family,  well  children  should  be  given  only  cooked  food.  Fruit 
must  be  peeled.  Water  for  washing  and  bathing  purposes  and  for  the 
cleansing  of  nursing  bottles  must  be  boiled.  Raw  milk  and  butter  may  be 
dangerous  vehicles  for  typhoid,  when  bacillus  carriers  come  in  contact  with 
it,  either  at  its  source  or  in  its  distribution. 

The  value  of  antityphoid  vaccination  has  been  repeatedly  demonstrated. 
The  protection  is  not  absolute;  some  cases  occur  among  the  vaccinatedr 
but  their  number  is  small.  Antityphoid  vaccine,  as  usually  administered 
in  the  United  States,  is  a  suspension  in  physiologic  sodium  chloride  solution 
of  killed  typhoid  bacilli  together  with  their  soluble  products  from  young 
agar  cultures.  One  cubic  centimeter  of  the  suspension  contains  1000 
million  bacteria.  At  present  a  triple  vaccine  is  used,  which  contains  1000 
million  typhoid  bacilli  and  750  million  of  each  of  the  paratyphoid  A  and  B 
bacilli,  in  each  cubic  centimeter.  The  vaccine  is  regularly  given  in  three 
doses,  two  days  or  a  week  or  ten  days  apart.  The  best  time  of  day  for 
administration  is  about  four  in  the  afternoon,  because  if  a  general  reaction 
supervenes,  the  greater  part  of  it  will  be  over  before  the  next  morning. 
The  vaccine  must  always  be  administered  subcutaneously  and  never  into 
the  skin  or  into  the  muscles  or  veins.  A  local  reaction  is  almost  invariably 
present,  while  the  general  reaction  may  be  absent,  mild  or  severe.  These 
reactions  ordinarily  subside  in  a  few  days  and  leave  no  sequela?. 

The  duration  of  the  immunity  is  difficult  to  establish,  but  it  seems  to  be 
a  matter  of  years  rather  than  months.  Revaccination  among  nurses, 
attendants  and  physicians  should  be  carried  out  annually. 

Children,  two  years  old  or  more,  bear  the  vaccination  better  than  adults, 
and  should  be  revaccinated  at  two  to  three  year  intervals.  Either  the 
regular  vaccine  dose,  namely  one  injection  of  500  million,  followed  by  two 
injections  of  1000  million  or  quarter  or  half  amount  of  the  above  doses  (100 
million  and  250  million  or  250  million  and  500  million)  can  be  used.  As  a 
rule  only  local  reactions  are  noted. 

Treatment. — The  treatment  is  chiefly  dietetic  and  physical,  since  no 
specific  remedies  are  available.  The  value  of  the  various  sera  is  still  too 
doubtful  to  justify  their  recommendation  for  general  use.  The  patient  and 
his  immediate  attendant  should  be  confined  to  one  room  and  complete 
changes  of  bedding  should  be  reserved  for  their  use.  A  rubber  sheet  may  be 
placed  over  the  mattress.  If  decubitus  threatens,  air  or  water  cushions  may 
be  provided.  Proper  care  of  the  skin  and  the  frequent  washing  with  alcohol 
of  the  parts  liable  to  pressure  are  important.  To  this  may  be  added,  later, 
suitable  attention  to  the  mouth.  The  nourishment  should  be  liquid  or 
semi-liquid  in  form  throughout  the  entire  course  of  the  disease.  Very 
young  children  may  be  given  mixtures  of  milk  and  gruel,  or  flour  soup  made 
with  milk  and  water.  For  somewhat  older  children,  heavier  gruels,  thin 
brown  flour  soup  with  milk,  cocoa,  etc.,  may  be  provided.  If  a  marked 
tendency  to  diarrhoea  is  shown,  the  quantity  of  milk  must  be  reduced  and 
the  use  of  flour,  dextrin  and  maltose  preparations,  etc.,  increased.  For  still 


THE  ACUTE  INFECTIOUS  DISEASES  697 

older  children  a  welcome  addition  to  the  diet  may  be  prepared  as  follows: 
Cornstarch,  80  grams  (2^  ounces),  is  stirred  into  a  little  water  and  brought 
to  a  boiling  point.  To  this  is  added  one  litre  (one  quart),  of  fresh  fruit  juice, 
made  from  currants,  raspberries,  etc.,  and  the  whole  is  boiled  for  a  few  min- 
utes. This  pudding  is  eaten  with  milk  and  sugar.  Gelatin  puddings  and 
finely  mashed  and  strained  apple  sauce  may  be  given  also.  In  long  and 
serious  cases  the  addition  of  fresh  meat-juice  to  the  gruels  [10-30  grams 
(^  to  1  ounce)  a  day],  may  be  recommended.  It  should  not  be  given  undi- 
luted. Food  should  be  given  every  three  hours  or  oftener,  and  even  every 
hour,  according  to  the  condition  of  the  patient.  Very  heavy  feeding  is 
objectionable.  A  liberal  quantity  of  fluid  is  important.  Water  or  weak  tea 
and,  if  there  is  no  diarrhoea,  water  with  fruit  j  uices  should  be  offered  to  the 
patient  frequently. 

As  the  fever  subsides  the  liquid  diet  may  be  replaced  gradually  by  solid 
foods;  but  for  diplomatic  reasons  it  should  be  continued  for  two  weeks  after 
the  disappearance  of  the  fever — that  is  until  all  danger  of  recrudescence 
is  passed.  After  this,  thick  gruels,  milk  toast,  mashed  potatoes,  spinach, 
and  chopped  meat  may  be  given.  Within  another  week  or  so,  rice,  mac- 
aroni, and  roast  meats  are  permissible. 

Medicinal  therapy  is  of  minor  importance.  If  a  cathartic  is  required 
at  the  onset  of  the  disease  it  is  as  well  to  replace  calomel  with  the  milder 
castor  oil.  It  may  be  given  in  two  doses,  of  one  or  two  tea  spoonfuls  each, 
at  an  interval  of  three  hours.  If  the  stools  are  very  frequent  and  watery, 
bismuth  subnitrate,  in  doses  0.5-1.0  gm.  (3-15  grs.),  or  tannalbin,  in  sim- 
ilar quantities,  three  times  a  day,  may  be  useful.  For  severe  headache  or 
for  persistently  high  fever,  a  dose  of  phenacetin,  from  0.1-0.4  gm.  (2-6 
grs.),  or  pyramidon  from  0.05-0.2  gm.  (1-3  grs.),  according  to  the  age  of  the 
child  may  be  given.  The  continued  exhibition  of  antipyretics  is  useless 
and  unless  the  dosage  is  very  carefully  regulated  is  harmful.  In  fact  their 
popularity  has  properly  yielded  to  the  virtues  of  hydrotherapy. 

Hydrotherapy  is  by  all  means  the  most  important  method  of  treatment 
in  children.  Tepid  baths,  given  twice  to  four  times  a  day,  as  soon  as  the 
temperature  rises  beyond  39°  or  39.5°  C.  (102°-103°  F.),  are  very  agreeable. 
For  children  over  five  years,  the  temperature  of  the  bath  should  be  ini- 
tially 33°-34°  C.  (91°-93°  F.),  and  should  be  cooled  rapidly  to  30°  C. 
(80°  F.).  With  younger  children  the  initial  temperature  should  be  main- 
tained. During  the  bath,  which  should  last  from  five  to  ten  minutes,  the 
limbs  and  back  should  be  rubbed  energetically.  If  the  patient  shows  apa- 
thy, somnolence,  or  delirium,  if  broncho-pneumonia  or  hypostasis  and 
defective  circulation  are  present,  the  tepid  bath  may  be  followed  by  a 
douche  of  cold  water,  given  by  means  of  a  bath-spray  or  a  sprinkling  can, 
and  poured  over  the  body.  This  may  be  repeated  a  number  of  times,  at 
intervals  of  half  a  minute.  This  treatment  causes  repeated  deep  inspira- 
tions. The  combined  bath  and  cold  douches  stimulate  the  nervous  system 
and  the  circulation  and  act  favorably  upon  the  respiration.  It  is  the  most 
satisfactory  weapon  for  combating  the  typhoid  state  and  the  development 
of  broncho-pneumonia.  The  lowering  of  the  body  temperature  by  this 


698  TEXT-BOOK  OF  PEDIATRICS 

means  is  a  secondary  and  less  important  matter.  If  the  fever  in  young 
children  is  persistently  over  40°  C.  (104°  F.),  cold  sponges  of  the  entire 
body  may  be  given  several  times  a  day.  With  older  patients,  packs  moist- 
ened with  water  at  room  temperature  may  be  used  morning  and  evening. 
The  patient  may  be  left  for  fifteen  minutes  in  the  pack,  which  may  be 
repeated  if  necessary.  An  ice-cap  may  be  applied  alternately  to  the  head 
arid  over  the  heart. 

In  younger  children  who  are  cyanotic  and  whose  circulation  is  poor, 
warm  baths  at  37°  C.  (98.6  F.),  rapidly  increased  to  40°  C.  (104°  F.), 
continued  from  three  to  five  minutes  and  followed  by  the  cold  douche,  act 
more  favorably  than  tepid  baths.  If  there  are  signs  of  collapse  the  cold 
douche  should  be  omitted.  If  the  heart  is  weakening,  a  little  coffee  with 
milk  may  be  given  as  a  stimulant  before  the  bath.  Frequently  repeated 
stimulation  is  required  and  for  this  purpose  caffein  is  very  useful  (page  415). 

Intestinal  hemorrhage,  of  rare  occurrence,  is  to  be  treated  by  absolute 
rest  and  the  administration  of  gelatin  subcutaneously  or  by  mouth.  Imme- 
diate surgical  interference  may  save  the  patient  if  perforation  occurs. 

During  the  period  of  defervescence,  quinine  is  a  good  tonic,  but  during 
the  febrile  stage  of  the  disease  the  indication  is  rather  for  the  use  of  an 
acid  mixture.  The  following  is  recommended: 

Grams 

1$    Acidi  hydrochloric!  diluti  2.0-4.0  (5ss-i) 

Syrupi  rubri  idaei  30.0  (5i) 

Aquae  destillatae  ad.  150.0  (5v) 

M.  Sig.    Two  teaspoonfuls  in  water  three  times  a  day. 

Even  in  mild  cases  the  patient  must  not  be  allowed  to  get  up  until  ten 
to  fourteen  days  after  the  fever  has  completely  disappeared.  If  the  con- 
valescence is  slow  the  patient  may  be  given  a  preparation  of  iron  and  qui- 
nine and,  if  possible,  should  be  sent  to  the  country. 

PARATYPHOID 

Bacteriologic  research  has  shown  within  recent  years  that  occasionally 
a  typhoid-like  disease  is  caused  by  organisms  of  the  same  group  as  the 
typhoid  bacillus.  Sometimes  the  disease  is  due  to  the  bacillus  paratypho- 
sus  A.,  which  resembles  the  typhoid  bacillus  in  many  respects  and  produces 
a  similar  disease-picture,  but  milder  in  character. 

A  disease  caused  by  the  paratyphoid  bacillus  B.  is  of  more  common 
occurrence  than  that  due  to  the  A.  type,  but  it  is  still  much  less  frequent 
than  that  due  to  the  typhoid  bacillus  itself.  It  is  contagious  and  occurs  in 
epidemics.  It  is  supposedly  carried  by  food.  Usually  its  disease-picture 
resembles  true  typhoid  very  closely.  Frequently  its  course  is  more  acute. 
The  rose  spots  and  the  diazo-reaction  are  less  constant  than  in  actual 
typhoid.  The  fever  often  has  a  remittent  character  and  the  remissions  are 
quite  frequent.  Intestinal  hemorrhages  may  occur  in  this  form,  but  it  is  not 
of  serious  degree.  Its  gastro-intestinal  and  septic  features  are  less  marked. 

A  diagnosis  can  be  made  by  bacteriologic  examination  alone.     This 


THE  ACUTE  INFECTIOUS  DISEASES  699 

should  be  directed  particularly  toward  the  agglutination  test  in  the  blood 
which  is  strongly  positive  for  paratyphoid  bacilli  and  persistently  negative 
for  the  typhoid  bacillus. 

INFLUENZA  AND  GRIPPAL  DISEASES 

In  1889-91,  influenza,  coming  out  of  Asia,  presented  a  disease  new  and' 
unknown  to  most  physicians  at  that  time.  It  spread  rapidly  as  a  great 
pandemic  over  all  of  Europe  and  to  other  civilized  countries.  Up  to  the 
onset  of  the  recent  pandemic,  cases  'have  been  infrequent  during  the  last 
few  years.  The  laity  and  the  profession  alike  have  encouraged  the  use  of 
the  term  influenza,  which  now  is  applied  with  freedom  to  the  group  of  febrile 
respiratory  disorders,  occurring  so  commonly  during  the  cold  season,  which 
formerly  went  under  the  designation  of  la  grippe.  This  indiscriminate 
use  of  the  term  is  a  disadvantage,  because  it  leads  many  to  believe  that  we 
still  have  to  deal  with  true  influenza;  whereas  the  term  la  grippe  had  come 
to  represent  a  quite  miscellaneous  group  of  conditions. 

It  seems  preferable  therefore,  to  reserve  the  name  influenza  for  that 
particular  pandemic  disorder  which  in  our  generation  was  first  recognized 
in  1889-90,  and  to  apply  the  term  la  grippe  to  this  large  number  of  other 
contagious  diseases  of  the  respiratory  tract.  La  grippe  may  occur  pan- 
demically,  epidemically,  or  in  endemic  form  (Filatow). 

The  influenza  with  which  I  had  an  opportunity  to  become  acquainted, 
as  a  young  physician  in  1889-90,  recurred  in  1918  as  an  extensive  pandemic 
and  traveled  over  the  entire  European  continent  in  a  much  more  malig- 
nant form  than  that  previously  observed.  Most  of  the  victims  were 
young  adults,  but  children  of  every  age  succumbed. 

Most  authors  designate  the  influenza  of  1918  as  la  grippe  or  Spanish 
influenza. 

In  discussing  this  subject,  contrary  to  the  custom  of  most  text-books, 
to  which  those  of  Filatow  and  Finkelstein  are  notable  exceptions,  it  seems 
proper  to  consider  not  influenza  alone,  but  distinctively  those  conditions 
which  are  represented  as  la  grippe.  In  la  grippe  we  do  not  have  to  deal, 
as  in  influenza,  with  a  specific  infectious  disease;  but  rather  with  etiologi- 
cally  different  diseases  and  probably  with  mixed  infections  which  produce 
similar  symptom-complexes.  The  separation  of  these  diseases  into  distinct 
groups  is  not  yet  possible,  since  their  clinical  and  bacteriological  peculiari- 
ties have  not  been  studied  sufficiently.  As  suggestive  of  the  variant  etiology 
of  the  group,  it  may  be  better  to  speak  of  grippal  diseases,  rather  than  of 
la  grippe  which  in  time  will  probably  be  resolved  into  a  number  of  distinct 
disorders.  At  present  it  is  only  possible  to  separate  pandemic  influenza, 
as  a  definite  entity,  from  among  this  general  group  of  diseases.  Even  this 
is  not  clinically  possible  as  it  was  upon  the  first  appearance  of  the  disease 
twenty-five  years  ago.  It  can  be  done  only  by  the  aid  of  bacteriologic 
examination.  The  points  of  similarity  and  difference  will  be  brought  out 
most  clearly  if  we  attempt  to  describe  influenza  and  grippal  disease  side 
by  side. 


700  TEXT-BOOK  OF  PEDIATRICS 

Etiology. — The  causative  organism  of  influenza  was  shown  by  Pfeiffer 
in  1890  to  be  a  specific  cocco-bacillus  found  abundantly  in  the  mucus  of  the 
nose  and  of  the  bronchi.  These  extremely  small  bacilli,  occurring  in  groups 
and  resembling  a  school  of  fish,  may  be  grown  upon  blood  or  upon  media 
containing  hemoglobin  or  two  vitamins.  They  stain  readily  with  carbol- 
fuchsin  and  die  rapidly  outside  the  human  body.  Since  the  bacillus  does 
not  penetrate  the  body,  many  of  its  disease  manifestations  must  be  consid- 
ered as  the  result  of  toxic  action.  Latterly  it  has  been  found  as  an  invader 
of  the  body  cavities  and  in  bronchiectasis,  etc.  It  is  not  infrequently  a 
common  saprophyte. 

The  views  dealing  with  the  etiology  of  influenza  during  1918  are  still 
very  much  divided.  Most  of  the  investigators  believe  that  the  influenza 
bacilli,  streptococci  and  pneumococci  which  are  found  in  this  disease  can 
only  be  considered  secondary  invaders.  Based  on  the  observations  of  two 
cases  of  meningitis  caused  by  a  pure  infection  of  influenza  bacilli,  the  author 
of  this  treatise  is  inclined  to  accept  the  view  just  mentioned. 

Olsen  found  in  more  than  two-thirds  of  the  cases  of  influenza  the  influ- 
enza bacillus  in  the  lungs  (166  times  in  222  cases).  In  recent  cases  these 
organisms  were  present  practically  in  pure  culture. 

The  causative  organisms  of  the  grippal  diseases  vary  in  different  epi- 
demics. The  most  common  of  these  is  the  pneumococcus  and  next  in  order 
of  frequency,  the  micrococcus  catarrhalis,  Friedlander's  bacillus  and  the 
streptococci ;  in  a  word,  those  germs  which  live  in  the  mouth  and  the  pharynx 
of  healthy  persons  as  parasites  and  which  appear  in  large  numbers  during 
attacks  of  la  grippe.  These  diseases  are  probably  due  less  to  an  increased 
virulence  of  the  organism  than  to  an  increased  local  sensitivity  of  the 
mucous  membranes.  This  increased  local  disposition  may  be  developed  by 
the  influences  of  a  rough  and  changeable  climate,  by  exposure  to  cold,  etc. 
Children  suffering  with  disturbances  of  nutrition,  or  with  lymphatic  or 
scrofulous  diatheses,  are  especially  predisposed.  It  is  not  impossible  that 
the  bacteria  mentioned  may  represent  in  part  merely  secondary  infections 
and  that  the  specific  organism  actually  causing  the  disease  is  still  unknown. 

The  method  of  transmission  of  influenza  and  of  the  grippal  diseases  is 
identical.  It  is  accomplished  by  direct  or  by  droplet  infection  in  coughing, 
sneezing,  etc.  Indirect  transmission  seems  to  be  very  rare,  particularly  in 
influenza.  The  contagiousness  of  these  diseases  is  extremely  great  and 
therefore  very  brief  contact  is  sufficient  for  infection.  Characteristic  of 
both  groups  of  diseases  is  their  constant  appearance  in  epidemic  form. 

Influenza  has  appeared  at  great  intervals  of  time,  arising  in  the  East 
and  spreading  through  Russia  to  Europe  where  it  has  developed  great 
pandemics.  These  major  outbreaks  soon  faded,  but  smaller  epidemics 
appeared  for  a  number  of  years  after  each  pandemic.  In  the  smaller,  com- 
munities, influenza  usually  spreads  so  rapidly  -that  the  entire  population  is 
affected  within  a  few  weeks.  Seasonal  and  meteorologic  conditions  do  not 
always  influence  its  spread. 

The  grippal  diseases  occur  regularly  during  seasons  of  inclement 
weather;  the  first  cases  usually  appear  with  the  onset  of  winter.  Frequently 


THE  ACUTE  INFECTIOUS  DISEASES  701 

large  epidemics  develop  in  the  wake  of  some  sudden  change  of  weather. 
These  epidemics  take  a  slower  course  than  those  of  influenza  and  may  per- 
sist for  many  months. 

Influenza  and  grippal  diseases  show  some  difference  in  respect  to  pre- 
disposition at  various  ages  of  life.  In  general,  influenza  affects  adults  and 
older  children  most  frequently.  Younger  children  are  less  commonly 
affected  and  if  they  suffer  it  is  generally  with  a  milder  form  of  the  disease. 
The  infants  of  affected  mothers  or  wet-nurses  often  escape  the  infection. 
The  grippal  diseases,  on  the  contrary,  are  most  common  in  early  childhood 
and  infancy  and  occur  in  very  severe  form  in  these  periods  of  life. 

Symptoms. — In  the  clinical  picture  of  the  individual  case,  it  is  usually 
impossible  to  distinguish  between  influenza  and  the  grippal  diseases.  As  in 
Asiatic  cholera  and  cholera  nostras  one  must  depend  upon  the  bacteriologic 
examination.  Influenza,  occurring  in  1891-92-93,  caused  disturbances  of 
the  respiratory  tract  which  developed  very  early  in  the  attack,  while  in  the 
early  history  of  the  pandemic  1889-90  these  symptoms  were  rarely  charac- 
teristic of  the  disease. 

The  points  of  similarity  in  the  two  disease-pictures  are  the  following; 
The  incubation  period  is  very  short,  covering  from  one  to  four  days.  After 
the  fever  sets  in,  it  may  rise  rapidly  to  40°-41°  C.  (104°-106°  F.).  It 
often  lasts  only  one  to  three  days  and  falls  by  crisis,  followed  by  perspira- 
tion. The  fever  is  frequently  of  a  remittent,  or  even  intermittent  type. 
Occasionally,  it  persists  for  an  entire  week  and  in  rare  instances  for  two  or 
three  weeks.  Very  commonly  a  prodromal  stage  occurs  in  the  grippal 
diseases,  with  coryza,  slight  cough  and  a  rise  of  temperature  preceding  the 
appearance  of  the  more  severe  symptoms.  In  influenza,  however,  a  sudden 
onset  is  the  rule. 

With  the  rise  of  the  temperature  there  is  often  vomiting,  reddening  of 
the  conjunctiva,  and  swelling  of  the  mucous  membrane  of  the  nose  and 
throat  which  at  first  is  without  increased  secretion.  An  intensely  livid 
injection  of  the  tonsils,  the  uvula  and  the  palatal  arch,  sharply  circum- 
scribed at  its  anterior  border,  is  noticeable.  The  usual  nasopharyngitis  is 
often  overlooked  in  younger  children  since  it  does  not  cause  very  marked 
nasal  discharge.  Enlargement  of  the  cervical  lymph  nodes  follows  which 
in  turn  causes  a  reflex  rigidity  of  the  muscles  of  the  neck,  suggesting  menin- 
gitis. In  infants  this  inflammation  occasionally  leads  to  retropharyngeal 
abscess.  Quite  frequently  in  individuals  of  the  lymphatic  type  the  infec- 
tion of  the  lymph  nodes  becomes  especially  prominent  and  may  occasion 
an  irregular  fever  for  weeks  after  the  original  disease  has  disappeared — a 
sequel  which  is  suggestive  of  tuberculosis.  An  annoying  dry  cough,  often 
of  hoarse  tone,  is  soon  in  evidence.  In  children  of  lymphatic  diathesis, 
pseudocroup  is  not  uncommon.  During  the  influenza  epidemic  of  1918-19, 
severe  forms  of  laryngitis  were  quite  frequently  noticed.  The  cough  may 
strongly  resemble  that  of  pertussis  and  may  even  provoke  vomiting.  Cough- 
ing spells  often  occur  during  the  night  and  may  present  serious  diagnostic 
difficulties.  It  is  important  to  note  that  these  short  but  intense  paroxysms 
of  coughing  occur  much  earlier  in  grippal  diseases  than  in  pertussis,  but, 


702  TEXT-BOOK  OF  PEDIATRICS 

as  in  the  latter,  the  lungs  and  bronchi  show  no  physical  changes  during  the 
first  few  days.  The  tendency  of  the  catarrha).  inflammation  to  spread  from 
the  throat  to  the  middle  ear  is  very  marked.  Children,  who  are  old  enough, 
often  complain  of  earache  even  on  the  first  day  of  the  disease;  in  younger 
ones  restlessness  and  persistent  crying  call  for  an  examination  which  elicits 
pain  upon  pressure  at  the  tragus  and  shows  reddening  of  the  tympanic 
membrane.  A  hemorrhagic  myringitis,  with  blood  filled  vesicles,  is  fre- 
quently seen.  The  accompanying  otitis  media  often  leads  to  suppuration 
and  perforation  of  the  drum.  During  the  pandemic  of  1918-19  the  ears 
were  very  slightly  affected. 

The  general  health  may  be  slightly  or  severely  affected  with  the  varying 
conditions  of  the  disease.  On  account  of  the  cough,  the  headache  and  ear- 
ache, sleep  is  often  restless  and  broken. 

If  the  fever  subsides  in  from  one  to  three  days  a  rapid  recovery  follows, 
the  cough  becoming  free  and  the  otitis  healing  speedily.  Very  often,  how- 
ever, the  fever  persists  and  the  inflammation  extends  to  the  mucous  mem- 
brane of  the  respiratory  tract,  as  a  whole,  involving  the  bronchi  and  the 
lung  alveoli.  This  is  an  especially  common  result  in  young  children.  Dys- 
pnoea, expansion  of  the  nostrils,  and  other  signs  of  broncho-pneumonia, 
become  apparent.  The  downward  spread  of  the  infection  may  be  so  rapid 
as  to  lead  one  to  suspect  a  lobar  pneumonia.  The  physical  signs  are  often 
surprisingly  like  it.  Commonly  the  gradual  extension  of  the  inflammation, 
the  numerous  rales  accompanying  it,  the  remittent  fever,  and  the  dela3red 
resolution  are  evidences  of  lobar  disease.  In  la  grippe  due  to  a  pneumococ- 
cus  infection,  the  similarity  of  the  picture  to  that  of  primary  pneumonia  is 
easily  understood  and  even  the  pathologic  findings  show  identical  condi- 
tions. In  other  cases,  again,  autopsy  shows  mixed  conditions  which  indi- 
cate that  lobar  pneumonia  and  broncho-pneumonia  may  exist  side  by  side. 
Sometimes  yellowish  foci  are  found  surrounding  the  bronchi,  while  associated 
with  these  is  a  dense,  varicolored  infiltration,  with  hemorrhagic  areas,  which 
is  essentially  cellular.  The  pandemic  of  1918-19  was  characterized  by  a 
predisposition  to  acute  pneumonia  of  hemorrhagic  and  necrotizing  character. 

Occasionally,  a  fibrinous  pleurisy  or  even  an  empyema  is  associated 
with  these  pneumonic  changes.  This,  in  turn,  may  lead  to  purulent  metas- 
tases  in  the  bones  or  joints,  to  septic  meningitis  or  to  pulmonary  abscess. 
In  the  early  years  of  life  pneumonia  is  the  most  common  and  the  most 
important  complication  or  rather  accompaniment  of  grippal  disease  and 
in  the  subjects  with  cachexia  or  nutritional  disturbances  it  is  often  fatal. 
In  the  ordinary  forms  of  grippal  disease  the  catarrhal  inflammations  of 
the  respiratory  tract,  from  coryza  to  pneumonia,  are  the  commonest  symp- 
toms. In  influenza,  however,  this  is  not  always  true.  In  the  pandemics  of 
1889-90  and  1918,  constitutional  disturbances  were  much  the  more  preva- 
lent. Aside  from  slight  catarrh  of  the  nose,  throat  and  conjunctiva,  the  air 
passages  were  often  unaffected,  particularly  in  young  children.  If  they 
were  affected,  the  involvement  did  not  occur  for  several  days. 

The  toxic  symptoms,  particularly  of  the  nervous  system,  are  always 
much  more  in  evidence.  Younger  children  are  unusually  weary;  older 


THE  ACUTE  INFECTIOUS  DISEASES  703 

patients  complain  of  severe  headache  and  backache  and  of  photophobia. 
Infants  cry  continually  and  are  exceedingly  restless.  An  extreme  desire 
for  sleep  may  deepen  into  stupor.  Hemorrhagic  encephalitis,  meningitis, 
hallucinations,  dementia,  neuralgias  and  neuritic  paralyses,  all  indicate 
how  seriously  the  nervous  system  may  be  involved.  In  late  childhood 
convalescence  in  such  cases  is  long  and  tedious,  even  though  the  attack  be 
of  short  duration.  This  nervous  type  is  much  less  common  in  the  grippal 
diseases.  Nevertheless,  severe  eclampsia  and  meningism  are  not  infrequent, 
but  they  are  associated  with  spasmophilic  diathesis  and,  therefore,  they 
occur  only  in  those  of  early  years. 

Gastro-intestinal  symptoms  may  be  prominent  alike  in  grippal  disease 
and  in  influenza;  they  represent  a  form  of  attack  which  is  recognized  also 
in  adults.  They  are  much  more  common,  however,  in  children.  In  fact, 
the  younger  the  patient  the  more  frequently  does  the  disease  take  this 
form.  During  an  epidemic  of  la  grippe  or  influenza  the  older  members 
of  a  family  may  have  a  febrile  bronchitis,  while  the  younger  children  vomit 
and  have  diarrhoea.  The  stools  may  be  watery  or  mucopurulent.  If  the 
fever  is  long  continued,  the  disease  may  present  a  picture  which  resembles 
in  some  respects  that  of  typhoid;  a  resemblance  may  be  further  supported 
by  the  appearance  of  an  exanthem  like  the  rose  spots  of  typhoid  fever,  but 
of  more  general  distribution  over  the  body. 

It  is  not  at  all  uncommon  to  find  other  forms  of  exanthemata  in  the 
course  of  the  disease.  These  are  usually  of  a  scarlatinoid  type  and  may 
create  much  confusion.  At  times  the  exanthem  resembles  either  measles 
or  rubella. 

In  influenza,  marked  disturbance  of  the  heart  indicates  the  toxic  influ- 
ence of  the  influenza  bacilli.  This  disturbing  influence  is  more  marked  in 
older  children;  in  whom,  as  in  adults,  it  may  cause  arhythmia,  a  small  and 
very  rapid  pulse,  dilatation,  and  even  heart  failure  at  any  time  during  the 
course  of  the  disease  and  even  in  convalescence.  Occasionally,  in  older 
children,  during  convalescence  of  an  uncomplicated  case,  the  pulse  may 
be  slow. 

The  spleen  is  always  enlarged  but  not  prominently  so.  Albuminuria  is 
common  in  all  the  diseases  of  this  group,  but  definite  nephritis  is  rare.  Hem- 
orrhagic nephritis  is  occasionally  seen.  The  diazo-reaction  is  but  rarely 
present.  During  the  first  days  of  the  attack  in  1918-19  epidemic,  the  blood 
showed  a  distinct  leucopenia. 

The  course  of  these  diseases  is  extremely  variable.  It  may  be  concluded, 
with  coryza  and  ephemeral  fever,  in  two  or  three  days.  It  may  be  so  mild 
that  it  is  entirely  overlooked.  It  may  last  for  eight  to  fourteen  days  as  a 
general  febrile  attack,  with  bronchitis  or  broncho-pneumonia.  Again,  it 
may  terminate  fatally  after  an  illness  varying  from  a  few  days  to  some 
weeks,  death  resulting  usually  from  some  secondary  purulent  infection,  as 
meningitis,  empyema,  etc.  There  are  probably  no  afebrile  forms  of  the 
disease,  but  in  frequent  ephemeral  cases,  the  physician  is  often  unable  to 
verify  a  rise  of  temperature.  Fever  may  be  entirely  lacking  in  infections 
of  atrophic  or  premature  infants  in  whom  collapse  speedily  occurs.  In 


704  TEXT-BOOK  OF  PEDIATRICS 

some  cases  a  chronic  bronchitis  develops  or  a  latent  tuberculosis  becomes 
active.  In  older  children  true  influenza  is  followed  by  a  slow  convalescence, 
with  neuralgia  and  persistent  weakness. 

Diagnosis. — Influenza  appears  as  a  general  infection  in  which  toxic  and 
nervous  symptoms  stand  out  prominently.  It  does  not  always  involve  the 
respiratory  tract  or  often  only  as  a  later  stage  of  the  disease.  In  fact,  the 
pandemic  of  1918-19  was  characterized  by  the  frequent  occurrence  of  very 
severe  pneumonias.  In  the  grippal  diseases  the  picture  is  definitely  one 
of  febrile  respiratory  disease.  These  differences,  however,  very  often  dis- 
appear, and  a  diagnosis  can  be  clearly  made  only  by  the  coincidence  of 
an  epidemic  or  by  a  bacteriologic  examination  at  the  hands  of  an  experi- 
enced bacteriologist. 

In  every  instance,  a  number  of  febrile  infections  must  be  considered  in 
making  a  differential  diagnosis.  In  typhoid,  the  fever  is  more  continuous. 
The  diazo-reaction,  the  rose  spots,  and  the  enlargement  of  the  spleen  ap- 
pear at  the  end  of  the  first  week.  In  true  lobar  pneumonia,  also,  a  more 
continuous  fever,  as  compared  with  the  marked  remissions  of  the  grippal 
diseases,  is  noticeable.  A  severe  accompanying  bronchitis,  the  extension 
of  the  inflammation  to  other  lobes,  the  delayed  resolution  and  the  absence 
of  the  crisis  contraindicate  pneumonia.  Intense  pain  in  the  limbs  may 
suggest  acute  rheumatism,  but  in  this  disease  the  involvement  of  the  respir- 
atory organs  is  wanting.  In  doubtful  cases,  conjunctivitis  and  otitis  indi- 
cate grippal  disease.  The  fever,  conjunctivitis,  coryza  and  cough  resemble 
the  initial  stages  of  measles.  Very  often  a  differential  diagnosis  can  be 
made  in  the  prodromal  stage  from  the  Koplik's  spots  alone.  In  the  grippal 
diseases,  the  scarlatinoid  exanthem  is  transitory  and  often  appears  only 
with  the  subsidence  of  the  fever.  The  angina  and  the  strawberry  tongue 
of  scarlet  fever  are  lacking.  The  suspicion  of  meningitis  frequently  causes 
anxiety  in  the  grippal  diseases.  In  influenza,  this  suspicion  is  aroused 
by  a  marked  somnolence,  and  in  other  grippal  diseases  by  an  accompany- 
ing otitis  and  a  swelling  of  the  cervical  lymph  nodes,  causing  reflex  rigidity 
of  the  neck.  Meningitis  is  also  simulated  by  a  spasmophilic  meningism. 
The  differentiation  is  all  the  more  difficult  because  a  true  meningitis  in 
either  the  serous  or  the  purulent  form,  and  due  to  either  the  pneumococcus 
or  the  influenza  bacillus,  is  not  so  very  uncommon  as  a  sequel  of  the  grip- 
pal  diseases. 

In  grippal  bronchitis,  as  compared  with  simple  bronchitis,  particularly 
intense  cough,  conjunctivitis,  high  fever  with  slight  constitutional  symp- 
toms, disturbed  sleep,  marked  malaise  and  nervous  irritability  are  more 
or  less  distinctive. 

The  differentiation  of  pertussis,  in  which  the  fever  is  very  slight  or 
entirely  wanting,  has  been  detailed  in  the  discussion  of  that  disease.  Very 
often  the  peculiar  cyanotic  reddening  of  the  throat  hi  la  grippe  determines 
a  diagnosis. 

The  prognosis  must  be  made  with  caution  even  in  the  mild  cases,  since 
the  coryza  with  which  the  disease  begins  is  very  often  only  the  introduc- 
tion to  a  severe  and  even  fatal  bronchitis  or  pneumonia  and  since  the  pos- 


THE  ACUTE  INFECTIOUS  DISEASES  705 

sibility  of  empyema  and  other  complications  must  be  remembered.  In 
infancy,  the  grippal  diseases,  often  taking  the  intestinal  form,  come  next 
in  fatality  to  the  primary  disturbances  of  nutrition.  Even  from  the  second 
to  the  fourth  year  many  weak  and  rickitic  children  succumb  to  them. 

Prophylaxis. — As  a  matter  of  prophylaxis,  therefore,  we  cannot  neglect 
the  slightest  coryza  or  cough  and  the  greatest  possible  care  should  be  exer- 
cised upon  the  appearance  of  even  the  milder  affections  of  the  respiratory 
tract.  It  is  extremely  important  that  young  children,  and  especially  those 
suffering  with  rickets  or  disturbances  of  nutrition  be  safe-guarded,  so  far 
as  possible,  from  infection.  Kissing,  the  use  of  common  handkerchiefs,  etc., 
should  be  strictly  avoided  even  when  the  child  is  well.  He  should  be  kept 
away  from  adults  who  have  coryza,  cough,  etc.  If  any  member  of  the 
family  shoAvs  symptoms  of  fever  or  of  nasal  or  bronchial  irritation,  from 
any  cause,  it  should  be  a  rule  of  ordinary  hygienic  behavior  to  keep  such  a 
one  isolated  from  the  child  as  fully  as  possible.  Very  often,  of  course,  the 
household  environment  makes  the  observance  of  such  a  rule  impossible. 

In  hospitals,  at  least,  children  with  febrile  disease  of  the  respiratory  tract 
should  be  strictly  isolated.  Never  should  they  be  allowed  in  the  same  ward 
with  infants. 

Treatment. — At  the  beginning  of  the  fever,  or  the  catarrhal  symptoms, 
diaphoretics  often  seem  to  bring  the  invasion  to  a  halt.  The  patient  should 
be  placed  in  a  warm  bed,  well  covered  and  be  given  two  doses,  at  intervals 
of  one  hour,  of  acetyl-salicylic  acid  of  0.1-0.5  gm.  (2-8  grs.),  graduated  to 
Ms  age.  Large  quantities  of  hot  drinks  should  be  given.  After  a  profuse 
perspiration  a  hot  bath  may  be  given  and  the  bed  and  body  clothing  changed. 
In  spasmophilic  or  lymphatic  children  these  diaphoretics  cannot  be  employed. 

Rest  in  bed  should  be  continued  for  several  days  after  the  fever  has 
subsided.  The  diet  should  be  liquid  and  of  scant  quantity  at  first,  espe- 
cially with  spasmophilics,  in  whom  the  development  of  convulsions  and 
meningism  dictate  a  brief  period  of  starvation,  which  together  with  cathar- 
sis often  gives  surprisingly  good  results. 

Upon  the  appearance  of  febrile  toxic  symptoms  a  mild  course  of  hy- 
drotherapeutic  treatment,  with  warm  baths,  followed  if  necessary  by  cold 
douches,  is  useful.  For  the  rest,  the  dominant  local  conditions,  in  nose,  ear 
or  respiratory  tract,  may  be  treated  as  they  arise. 

Disturbances  of  nutrition  should  be  managed  as  detailed  in  the  chap- 
ters dealing  with  these  conditions. 

Threatening  cardiac  weakness  demands  rest  and  stimulants,  caffein,  at 
the  proper  time.  The  use  of  large  doses  of  camphorated  oil  (twenty  per 
cent.)  in  doses  of  5  c.c.  twice  daily,  or  in  older  children  10  c.  c.  subcutane- 
ously  or  better  intramuscularly,  produced,  in  the  experience  of  the  author, 
beneficial  results. 

Following  severe  cases  of  long  duration,  tonics,  preferably  of  quinine 
and  iron,  may  be  given  during  convalescence.  Later  a  visit  to  the  country 
or  the  mountains  is  beneficial  and  is  a  preventive  of  tuberculous  conditions. 
45 


706  TEXT-BOOK  OF  PEDIATRICS 

ACUTE  ARTICULAR  RHEUMATISM 

(POLYARTHRITIS  ACUTA) 

Acute  articular  rheumatism  is  a  febrile  disease,  which  is  marked  by 
transitory,  non-suppurative  inflammation  of  several  joints  and  frequently 
produces  inflammatory  lesions  of  the  heart. 

Verified  knowledge  of  the  nature  of  the  disease  is  still  limited.  Doubt- 
less processes  differing  in  their  etiology  are  grouped  by  means  of  similar 
symptom-complexes.  This  is  especially  true  in  the  chronic  forms  grow- 
ing out  of  the  acute  disease.  Many  facts  suggest  that  in  the  major  number 
of  cases  coming  under  this  head,  we  are  dealing  with  an  infectious  disor- 
der. Some  authorities  hold'  that  it  is  a  matter  of  a  feeble  form  of  sepsis. 
It  becomes,  however,  more  and  more  apparent  that  in  pure  types  of  in- 
flammatory rheumatism,  the  blood,  the  joints,  and  the  heart  valves  are 
sterile.  Hence  we  must  conclude  that  the  causative  organism  is  still  un- 
known (Jochmann). 

The  fact  that  several  cases  of  the  disease  appear  coincidently  in  a  single 
house  and  that  the  disease  is  often  preceded  by  angina  seems  to  indicate 
an  infectious  agent. 

The  predisposing  factor  of  age  shows  great  variability.  The  disease  is 
very  rare  between  two  and  five  years;  it  is  more  common  between  five  and 
ten  and  very  frequent  between  ten  and  fifteen.  A  few  cases  have  been 
described  in  which  a  mother  with  articular  rheumatism  has  given  birth  to  a 
child  who  has  shown  symptoms  of  the  disease  at  birth.  These  instances 
are  very  doubtful,  as  is  the  occurrence  of  any  case  in  infancy. 

The  attempt  has  been  made,  again  and  again,  to  determine  the  influence 
of  heredity,  but  without  positive  result.  The  relationship  of  cold-taking,  or 
of  residence  in  damp  dwellings,  has  been  suggested  but  it  is  difficult  to 
attach  any  significance  to  these  factors.  The  marked  tendency  of  certain 
persons  to  repetitional  attacks  in  the  course  of  several  months  and  years 
suggests  the  importance  of  individual  predisposition,  the  basis  of  which  is 
not  as  yet  clear.  Sometimes  a  familial  tendency  is  apparent.  The  disease 
as  it  occurs  in  childhood  demands  special  attention,  since  it  offers  a  number 
of  very  marked  differences  from  the  typical  forms  seen  in  later  life.  These 
peculiarities  consist  in  the  minor  importance  of  the  joint  affections  as  com- 
pared with  the  constitutional  disturbance,  in  the  imminence  of  serious  and 
permanent  heart  complications  and  in  its  frequent  association  with  chorea 
minor  (see  page  549). 

As  in  the  adult,  the  disease  usually  begins  with  evidence  of  inflammation 
in  the  joints,  sometimes  of  sudden  and  intense  and,  again,  of  gradual  and 
insidious  development.  Comparatively  often,  however,  general  disturb- 
ances, by  way  of  lassitude,  anorexia  and  slight  fever,  take  a  primary  place 
in  the  clinical  picture  in  the  first  few  days.  Frequently  the  attack  begins 
with  a  catarrhal  or  lacunar  angina,  justifying  the  assumption  that  the  organ- 
isms causative  of  the  disease  find  their  port  of  entry  in  the  tonsils;  as  they 
do,  in  great  measure,  in  infection  of  the  adult  with  rheumatism  or  sepsis. 

The  joint  manifestations  are  usually  so  slight  and  so  transitory  that 


THE  ACUTE  INFECTIOUS  DISEASES  707 

they-  are  often  overlooked.  This  is  particularly  apt  to  be  true  when  they 
are  of  late  appearance  and  when  the  attention  of  the  physician  has  been 
centred  upon  the  angina  and  the  general  health  disturbance.  Hardly 
ever  do  they  become  as  severe  as  in  the  adult.  They  appear  most  commonly 
in  the  knee,  foot,  or  shoulder  joints  and  do  not  persist  for  any  length  of 
time  in  any  one  joint.  The  number  of  joints  affected  is  usually  less  than  in 
the  adult.  The  cervical  vertebral  column  is  involved  with  relative  fre- 
quency. The  swelling  of  the  joints  is  usually  insignificant  and  is  apt  not 
to  attract  attention  unless  it  is  specifically  sought.  The  oversight  is  the 
more  likely  since  reddening  of  the  surface  occurs  only  in  exceptional  cases. 
Palpable  exudation  in  the  joints  is  ordinarily  lacking.  Very  often  no  swell- 
ing can  be  discerned  and  the  affection  of  the  joint  is  apparent  only  from 
the  tenderness  which  leads  to  fixation  and  in  young  children  to  the  main- 
tenance of  eccentric  postures.  Frequently  the  tenderness  is  discovered 
only  by  systematic  examination  of  all  the  joints  and  by  the  exercise  of 
pressure  and  passive  motion.  Indeed  cases  are  recorded  in  which  cardiac 
lesions,  or  chorea  are  discovered  and  a  carefully  elicited  history  relates 
that  the  child  had  complained  of  slight  transitory  pains  in  one  foot  or  knee 
some  few  weeks  or  months  previously. 

The  fever  is  usually  moderate,  varying  between  38°  and  39°  C.  (100°- 
102°  F.),  rarely  more  and  often  even  less.  While  the  temperature  may 
fall  to  the  normal  range  for  a  few  days  it  rises  again  as  some  other  joint  is 
newly  involved. 

No  such  constant  relation,  however,  between  the  temperature  and  the 
joint  manifestations  always  obtains;  and  it  may  well  be  supposed  that  the 
general  rather  than  the  local  infection  upon  which  the  implication  of  other 
organs,  as  the  heart,  depends,  may  readily  escape  observation  and  yet  play 
an  important  part. 

Sweats  frequently  occur,  but  are  not  usually  so  profuse  nor  of  so  acid  a 
quality  as  in  the  adult. 

A  certain  degree  of  involvement  of  the  heart  is  so  common,  occurring  in 
from  eighty  to  ninety  per  cent,  of  all  cases,  that  it  may  be  said  to  belong  to 
the  regular  course  of  the  disease  and  to  dictate  frequent  examination  of  the 
organ.  Examined  daily  from  the  very  beginning  of  the  attack,  a  slight 
systolic  murmur  will  be  heard  at  the  apex,  in  very  many  cases,  toward  the 
close  of  the  first  week.  For  a  long  time  it  is  impossible  to  say  whether  the 
murmur  is  functional  or  is  the  sign  of  endocardial  infection  of  the  mitral  valve. 

Observation  shows  that  these  murmurs  of  acute  rheumatism  and  chorea 
are  extremely  difficult  to  interpret.  Considering,  however,  that  a  definite 
valvular  lesion  appears  sooner  or  later  in  the  large  majority  of  cases,  it  is 
fair  to  suppose  that  the  remaining  number  which  develop  no  dilation  of  the 
heart  and  no  accentuation  of  the  pulmonic  second  sound  and  in  which  the 
murmur  disappears  within  a  few  weeks  or  months,  suffer,  nevertheless,  a 
slight  endocarditis.  la  many  instances  the  heart  lesion  becomes  apparent 
even  during  the  attack  of  rheumatism,  but  in  other  cases  it  is  not  evident 
until  after  recovery  from  the  acute  disease.  Endocarditis  is  most  apt  to 
appear  at  an  early  date  when  pericarditis  is  associated  with  it.  Not  infre- 


708  TEXT-BOOK  OF  PEDIATRICS 

quently  it  appears  coincidently  with  the  onset  of  the  rheumatism  and  may 
even  precede  the  latter,  an  indication  that  the  joint  affections  are  merely 
symptoms  of  a  general  infection. 

The  duration  of  acute  rheumatism  is  rarely  over  fourteen  days,  saving 
in  certain  unusual  forms.  Indeed,  cases  are  observed  in  which  the  joint 
manifestations  permanently  disappear  within  a  week;  but  again,  as  in  the 
adult,  severe  cases  with  complications  may  drag  on  for  man}'  weeks.  Relapses 
are  not  uncommon.  They  may  occur  immediately  after  the  initial  attack, 
the  same  or  other  joints  being  affected  or  they  may  be  postponed  for  weeks. 
Repeated  attacks  may  be  observed  in  the  course  of  months  or  years. 
Rheumatism,  endocarditis,  and  chorea  may  appear  in  rotation  in  the  one 
individual;  e.  g.,  endocarditis  may  occur  six  months  after  an  attack  of 
rheumatism;  within  the  year,  chorea  may  develop;  and  again  later  another 
attack  of  rheumatism,  etc.  In  such  rotary  cases  rheumatism  may,  at  one 
time,  appear  first;  on  another  occasion,  chorea  is  the  first  manifestation;  or, 
again,  endocarditis  may  take  the  precedence.  Evidently  each  and  all  are 
expressions  of  one  and  the  same  infectious  disease.  In  severe  and  threaten- 
ing cases,  the  triad  of  symptoms  is  simultaneously  present.  Occasionally, 
the  rheumatism  disappears  suddenly  and  is  replaced,  in  a  degree,  by  a 
definite  chorea, 

PECULIARITIES  OF  COURSE  WITH  THE  IMPLICATION  OF  VARIOUS  ORGANS 

Heart  complications  take  a  prominent  place  in  the  clinical  picture  of 
the  disease,  not  only  on  account  of  their  frequency  but  also  because  of  their 
importance.  Rheumatism  is  the  cause  of  more  valvular  lesions  in  childhood 
than  it  is  in  adults.  Endocarditis  may  occur  at  any  time.  Very  often  a  child 
is  supposed  to  have  survived  an  attack  of  rheumatism  without  permanent 
injury.  Upon  casual  examination,  however,  months  later  arid  when  no  other 
illness  has  supervened,  a  distinct  valvular  lesion  is  found.  The  lesion  is  al- 
most always  that  of  mitral  insufficiency.  Aortic  insufficiency  is  rare.  The  ob- 
servant parent  may  report  that  the  child  has  been  habitually  tired  and  pale 
in  the  interval  since  the  attack  of  rheumatism,  and  his  temperature  may  be 
found  as  high  as  37.5  or  38°  C.  (99.5-100.5°  F.).  Frequency  of  pulse-rate 
and  cardiac  dilatation  may  be  wanting.  On  the  other  hand,  the  endocarditis 
may  be  apparent  even  during  the  acute  attack  of  rheumatism  and  may  lead 
rapidly  to  the  development  of  symptoms.  A  marked  systolic  murmur  at 
the  mitral,  an  accentuated  pulmonic  second  sound,  cardiac  dilatation,  an 
increased  pulse-rate,  dyspnoea,  precordial  oppression,  a  renewal  of  fever 
due  to  further  involvement  of  the  joints,  etc.,  will  ensue.  Fortunately  the 
inflammation  extends  to  the  myocardium  and  the  pericardium  in  only  a 
small  number  of  cases. 

Pericarditis  is  almost  always  associated  with  endocarditis  and  is  a 
severe  and  extremely  dangerous  affection.  It  is  often  fatal,  even  in  the 
acute  stage,  either  in  consequence  of  the  cardiac  insufficiency,  resulting 
from  the  accompanying  myocarditis,  or  from  compression  of  the  heart  by 
the  large  accumulation  of  serous  exudate.  Very  frequently  it  passes  into 
the  chronic  form.  In  small  circumscribed  areas  of  infection,  local  oblitera- 


709 


tion  of  the  pericardial  space  occurs,  while  with  more  general  involvement, 
obliteration  often  takes  place  after  the  exudate  has  been  resorbed.  This 
results  in  death  after  months,  or  even  a  year  or  two,  of  extreme  suffering. 
Pericarditis  is,  in  fact,  the  most  common  cause  of  death  in  either  acute  or 
chronic  stages  (see  pericarditis  page  407). 

Fibrinous  pleurisy  is  not  uncommon  and  the  exudative  form  is  even 
more  frequent.  It  is  usually  coincident  with  pericarditis.  The  exudate  is 
generally  completely  absorbed  if  the  pericarditis  does  not  cause  death. 

Severe  cerebral  symptoms  are  rare,  but  they  give  a  very  grave  prognosis. 
In  very  serious  cases  attended  with 
high  fever  41°  C.  (105°  F.  or  more), 
they  take  the  form  of  delirium,  with 
other  evidences  of  meningitic  irritation, 
followed  speedily  by  coma  and  death. 

Various  forms  of  erythemata  occa- 
sionally appear.  These  are  either  of 
the  multiform  or  marginate  exudative 
type,  or  of  the  papular  variety.  It 
must  be  remembered  that  an  endocar- 
ditis often  develops  in  the  course  of  a 
traumatic  erythema.  Rarely  have  pale 
or  erythematous  areas  of  painful  edema 
been  described. 

An  unusual  form  of  disease,  seen 
almost  exclusively  in  children,  is  rheu- 
matism nodosum  (Fig.  178).  In  the 
course  of  extreme  cases,  with  cardiac 
complications,  nodules,  varying  in  size 
from  that  of  a  pinhead  to  that  of  a 
cherry,  and  painful  upon  pressure,  ap- 
pear upon  the  surface  of  the  joints, 
most  frequently  of  the  elbow  or  along 
the  course  of  the  large  tendons,  or 
on  the  scalp.  The  nodules  may  be 
very  numerous,  but  they  usually  dis- 
appear after  a  short  time.  They  are  of  fibrous  structure. 

The  diagnosis  of  inflammatory  rheumatism  is  readily  made  in  advanced 
cases.  In  children,  however,  mistakes  are  very  common,  especially  when 
there  are  neither  objective  nor  subjective  manifestations  of  joint  infection 
or  when  the  cardiac  symptoms  dominate  the  disease-picture. 

Differentially  a  number  of  diseases  which  cause  pain  and  inflammation 
in  or  about  the  joints  must  be  considered.  Syphilitic  osteochondritis  is 
readily  excluded,  since  it  occurs  only  in  young  infants  and  will  be  associated 
with  other  symptoms  of  syphilis.  This  is  equally  true  of  the  painful  joints 
of  florid  rickets  and  infantile  scurvy.  In  addition,  a  number  of  specific 
and  septic  infections  which  cause  metastases  in  the  joints  must  be  taken 
into  account.  These  constitute  the  so-called  rheumatoid  diseases.  Among 


FIG.  178. — Rheumatism  nodosum.     Six-year- 
old  child. 


710  TEXT-BOOK  OF  PEDIATRICS 

these,  pneumococcic  arthritis  is  the  most  important.  This  is  a  frequent 
sequela  of  pneumonia  or  empyema  in  young  children,  often  affecting  several 
of  the  large  joints,  and  usually  proving  benign  in  spite  of  a  purulent  exudate. 
The  rheumatism  of  scarlet  fever  is  especially  innocent.  It  often  develops 
in  the  second  week  of  the  disease  and  is  most  commonly  located  in  the 
wrist.  It  soon  disappears  without  leaving  permanent  injury.  A  severe 
pyemic  inflammation  of  the  joints  which  may  occur  in  scarlet  fever  or  in 
any  form  of  septic  disease  must  not  be  confused  with  it.  Gonorrhoeal  arthri- 
tis is  less  common  after  vulvovaginitis  than  it  is  after  ophthalmia.  It 
occurs  within  two  to  four  weeks  after  the  primary  infection.  It  generally 
affects  the  knee  and  the  hip-joint,  and  often  only  one  of  them.  It  causes  a 
painful  red  swelling.  Its  prognosis  is  usually  good.  These  various  possibilities 
must  be  weighed  in  every  case  of  rheumatism,  especially  of  a  rnonoarticu- 
lar  form  and  the  vulva  and  the  conjunctiva  should  be  carefully  examined. 
The  exudate  in  the  joint  contains  gonococci.  It  must  be  remembered 
that  hereditary  lues  not  infrequently  causes  chronic  inflammation  of  the 
joints  in  older  children.  This  disease  is  remarkable  for  the  absence  of  pain 
and  for  the  fact  that  it  most  frequently  appears  in  the  form  of  bilateral 
hydrops  of  the  knee.  Often  it  is  associated  with  a  painful  hyperplastic 
periostitis  of  the  tibia. 

Tuberculous  rheumatism  occupies  a  peculiar  place.  It  has  been  described 
most  fully  by  such  French  authors  as  Poncet  and  others  but  has  not  been 
fully  accounted  for.  Tuberculous  individuals,  or  rather  persons  inclined 
to  tuberculosis,  are  met  with  in  whom  affections  of  the  joints  and  of  the 
vertebral  column  appear  in  their  early  history  and  these  cannot  be  distin- 
guished from  ordinary  rheumatism.  Only  by  their  obstinacy  to  ordinary 
treatment,  by  the  fact  that  the  involved  joints  are  few,  by  their  chronic 
course,  and  the  coincidence  of  tuberculosis  in  other  parts  is  their  etiology 
recognized.  The  reader  should  be  reminded  that  tuberculous  coxitis,  in  its 
onset,  may  very  closely  resemble  rheumatism  of  the  hip  or  knee. 

The  prognosis  of  acute  articular  rheumatism  must  be  made  very  cau- 
tiously. The  joint  affections  almost  always  recover  without  leaving  any 
permanent'  injury  and  only  in  exceptional  instances  do  they  pass  into  the 
chronic  form. 

From  one-half  to  two-thirds  of  all  cases  are  left  with  a  chronic  heart 
lesion.  In  a  few  cases  death  results  from  the  severe  infection  during  the 
acute  stage;  more  frequently  the  patient  succumbs  to  pericarditis  in  the 
course  of  years.  Even  patients  who  pass  through  the  acute  stage  well  are 
liable  to  later  recurrences  or  to  chorea  or  cardiac  lesions. 

The  treatment  is  the  same  as  in  the  adult.  Rest  in  bed,  a  carefully 
warmed  room  and  the  avoidance  of  draughts  are  essential.  The  salicylates 
should  be  used  in  every  case.  Sodium  salicylate  may  be  given  to  infants 
in  doses  of  0.25  gram  (4  grs.) ;  to  children  of  from  three  to  five  years,  0.5 
gram  (7^  grs.) ;  and  to  children  of  from  eight  to  ten  years  1.0  gram  doses 
(15  grs.),  three  times  a  day.  Doses  of  acetyl-salicylic  acid  (aspirin),  should 
be  a  little  smaller.  After  the  fever  and  the  inflammation  of  the  joints  have 
subsided,  medication  should  be  continued  for  at  least  a  week,  but  during 


THE  ACUTE  INFECTIOUS  DISEASES  711 

that  time  the  doses  may  be  reduced  to  one-half,  and  then  to  one-third  of 
the  original  quantity.  Many  cases  react  favorably  to  the  salicylates.  If 
they  fail  of  results,  antipyrin  may  be  tried  in  doses  of  0.2-0.7  gm.  (3^-10 
grs.),  three  times  a  day.  The  joints  should  be  fixed  and  wrapped  in  cotton. 
Later,  warm  baths  with  massage  are  desirable.  Hot  baths  from  the  begin- 
ning are  often  recommended.  The  heart  complications  are  treated  accord- 
ing to  the  usual  measures,  elsewhere  described  in  this  volume.  Even  when 
all  the  joint  symptoms  have  disappeared,  if  fever  still  persists  the  patient 
must  be  kept  in  bed,  because  of  the  possibility  of  endocarditis.  In  such 
cases  and  in  those  of  advanced  endocarditis  small  doses  of  the  salicylates 
are  probably  useful  even  though  it  is,  generally  speaking,  impossible  to 
prevent  endocarditis  or  valvular  lesions  by  their  use. 

The  diet  should  be  light  and  very  little  meat  should  be  given.  Alcohol 
must  be  avoided. 

After  the  rheumatism  has  subsided,  careful  efforts  should  be  made  to 
increase  the  resistance  of  the  patient.  At  first,  dry  rubs  with  rough  flannels 
should  be  given,  these  should  be  followed  with  alcohol  rubs  and  later  by 
sponge  baths  with  water  at  room  temperature.  In  the  cold  season  the  pa- 
tient should  wear  woolen  undergarments.  As  after  treatment,  if  all  the 
joint  symptoms  have  not  disappeared,  sun-baths  or  sulphur-baths  may  be 
recommended.  In  chronic  cardiac  conditions,  the  mild  Nauheim  treatment 
may  prove  beneficial. 

CHRONIC  RHEUMATISM 

Chronic  rheumatism  is  even  less  a  specific  disease  than  is  the  acute 
form.  Its  customary  subdivisions  may  be  dismissed  with  a  word. 

Two  forms  are  readily  distinguished.  First,  a  secondary  form  arising  in 
cases  of  acute  rheumatism  which  do  not  recover  completely;  in  which  new 
attacks  develop  from  time  to  time,  and  which  lead  to  permanent  joint 
changes.  These  cases  often  begin  acutely  and  show  intercurrent  febrile 
attacks.  The  exacerbations  often  seem  to  spread  from  centres  of  infection, 
as  from  the  large  joints  of  one  extremity  to  the  smaller  joints  of  the  hands 
and  feet.  The  frequent  appearance  of  endocarditis,  or  rather  of  valvular 
lesions  in  these  cases  may  be  readily  understood.  They  rarely  react  to  the 
salicylates,  but  may  recover  after  many  months  under  treatment  with  hot 
baths,  massage,  mud-baths,  etc.  Certain  forms  of  so-called  tuberculous 
rheumatism  develop  in  a  similar  manner. 

The  second  type  is  that  of  primary  chronic  articular  rheumatism.  This 
includes  a  group  of  diseases,  which  are  as  variable  and  as  obscure  in  child- 
hood, as  in  the  adult;  although  they  are  much  less  frequent.  A  certain 
number  of  these  cases  begins  insidiously  either  without  fever  or  with  a  very 
slight  rise  of  temperature.  The  joints  of  the  toes  and  fingers  or  of  the 
wrist  and  ankle  are  first  affected,  and  then  one  joint  after  another  is  gradu- 
ally, but  with  gruesome  certainty,  involved.  Cardiac  changes  are  of  rare 
occurrence  and  this  fact  alone  casts  doubt  upon  the  true  rheumatic  origin 
of  the  disease.  This  is  also  indicated  by  the  fact  that  it  frequently  appears 
between  the  second  and  the  fourth  year.  Fixation  of  the  vertebral  column 


712 


TEXT-BOOK  OF  PEDIATRICS 


is  relatively  common.  In  many  cases,  a  knob-like  thickening  of  the  phalan- 
geal  joints  is  observed,  which  in  the  secondary  form  of  chronic  rheumatism 
appears  later  and  is  hardly  ever  so  noticeable  a  feature.  No  other  very 
distinctive  differences  are  determinable,  at  least  in  the  more  advanced 
cases.  Subsequently,  the  capsule  of  the  joint  often  becomes  thickened 
and  shrinks.  The  cartilages  are  eroded  and  undergo  fibrinous  changes. 
The  joints  are  ankylosed.  The  bones  and  even  more  markedly  the  muscles 
atrophy.  In  a  case  which  eventually  recovered,  spontaneous  dislocation  of 
one  hip-joint  has  been  seen  (Fig.  179).  The  disease  progresses  slowly 
through  a  term  of  years  and  yet  much  more  rapidly  than  it  does  in  the 

adult.  With  the  fixation  of  the  spine  severe 
contractures  develop  which  are  especially 
painful.  Arthritis  deformans  of  the  hip- 
joint  is  not  uncommon  in  older  children  and 
is  often  treated  for  a  long  period  as  tuber- 
culous coxitis. 

A  peculiar  form  of  the  disease  was  de- 
scribed by  Still,  in  which  the  several  joints 
of  the  extremities  and  the  cervical  vertebrae 
were  gradually  ankylosed.  The  process  was 
practically  painless.  It  developed  in  a 
series  of  attacks,  accompanied  by  fever  and 
by  an  enlargement  of  the  spleen  and  the 
lymph  nodes.  The  joints  themselves  were 
not  destroyed. 

The  prognosis  of  the  secondary  form  is 
undoubtedly  better  than  that  of  the  primary 
chronic  type,  from  which,  however,  recover- 
ies have  occurred.  Death  usually  results 
from  general  exhaustion  or  from  secondary 
infections. 

In  the  differential  diagnosis  of  these  con- 
ditions tuberculosis  and  syphilis,  traumatic 
injury  to  the  epiphyses,  and  occasionally 
joint  changes  incident  to  hemophilia,  must  be  considered. 

In  the  treatment  of  the  group,  the  salicylates  should  be  tried  in  every 
case.  They  may  have  a  favorable  action  in  the  secondary  forms.  Potas- 
sium iodide  and  arsenic  may  be  given.  In  some  instances  thyroid  prepara- 
tions have  been  found  very  useful.  Recently  beneficial  results  have  been 
reported  by  the  use  of  non-specific  protein  shock  therapy  (injections  of 
milk,  etc.).  The  best  results,  however,  are  obtained  by  physical  measures, 
in  the  way  of  massage,  passive  motion,  hyperemic  stasis,  and  the  various 
baths.  Sun-baths,  mud-baths,  sand,  and  sulphur-baths,  in  addition  to 
hydrotherapeutic  methods,  have  been  employed.  If  but  few  joints  have 
been  affected,  the  results  may  be  improved  subsequently  by  tenotomies, 
orthopedic  apparatus,  etc. 


FIG.  179. — Chronic  articular  rheuma- 
tism. Girl  three  and  one-half  years  old. 
Marked  swelling  of  all  the  larger  joints 
of  the  extremities  and  of  the  joints  of 
the  fingers. 


THE  ACUTE  INFECTIOUS  DISEASES  713 

ERYSIPELAS 

Erysipelas  is  an  acute  inflammation  of  the  skin,  spreading  by  way  of 
the  lymph  channels  and  featured  by  circumscribed  raised  margins  between 
the  inflamed  portion  and  the  normal  skin.  It  is  accompanied  sometimes 
by  mild  and  sometimes  by  severe  general  symptoms.  It  is  almost  invariably 
of  streptococcic  origin.  The  disease  is  much  more  rare  in  children  than  in 
adults.  In  the  new-born  it  plays  a  special  role  and  is  comparatively  fre- 
quent. In  later  childhood  it  takes  a  very  minor  part,  but  toward  puberty, 
again,  it  grows  more  common. 

Etiology. — Excepting  in  the  first  few  days  of  life,  when  the  umbilicus 
forms  a  special  port  of  entry,  true  wound  erysipelas  is  rare  in  this  period, 
and  especially  so  since  two  other  factors,  formerly  of  frequent  influence, 
viz.,  vaccination  and  circumcision,  are  now  of  minor  importance,  thanks 
to  the  improvement  of  surgical  technic.  Formerly  erysipelas  often  ap- 
peared in  the  vaccination  area  and  may  have  been  primarily  due  either 
to  infection  of  the  virus  with  streptococci,  or  to  carelessness  and  want  of 
cleanliness  in  the  operation  itself;  or  it  may  have  been  secondarily  due  to 
the  scratching  of  the  pustule  with  dirty  finger-nails,  an  accident  which 
still  occasionally  happens.  In  older  children  erysipelas  arises  in  a  large 
number  of  instances  from  the  nose,  as  it  does  in  adults,  the  excoriations  of 
anterior  rhinitis  sicca  affording  a  ready  port  of  entry.  In  younger  children 
a  number  of  other  points  of  possible  invasion,  such  as  eczematous  skin 
lesions,  fissures  of  the  lips,  ears,  and  genitals,  scratched  chicken-pox  pus- 
tules, etc.,  present  themselves. 

Frequently,  the  disease  arises  by  auto-infection,  since  streptococci  are 
often  found  in  the  mouth  or  nose,  upon  the  unclean  skin,  in  eczematous 
sores,  etc.,  for  reasons  not  yet  understood,  the  streptococci  in  these  areas 
suddenly  become  virulent.  In  children,  the  disease  probably  begins  in  the 
throat  less  frequently  than  it  does  in  the  adult.  The  development  of 
erysipelas  is  doubtless  due  also  to  a  reduced  power  of  resistance.  This  is 
particularly  true  in  weak,  premature  infants  or  in  those  suffering  with 
disturbances  of  nutrition.  It  is  really  strange  that,  barring  the  new-born, 
erysipelas  is  so  rare  among  infants,  in  whom  sepsis  is  so  common  and 
especially  since  their  extreme  liabilities  to  intertrigo,  eczema,  impetigo, 
etc.,  give  ample  opportunity  for  the  entrance  of  streptococci.  It  rather 
gives  one  the  impression  that  the  lymphatic  system  of  the  child's  skin 
does  not  readily  admit  superficial  infection. 

Erysipelas  is  generally  a  matter  of  indirect  transmission.  Formerly, 
when  cleanliness  was  not  strenuously  enforced  in  hospitals  and  the  knowl- 
edge of  asepsis  and  antisepsis  was  scant,  infection  with  erysipelas  was  a 
common  occurrence,  as  is  shown  by  the  records  of  old  lying-in  hospitals, 
foundling  asylums,  and  even  surgical  wards.  Now-a-days  the  conveyance 
of  erysipelas  from  one  case  to  another  in  hospital  is  extremely  uncommon. 
Even  when  a  mother  has  the  disease  the  infection  of  her  infant  is  rare. 

The  clinical  course  of  erysipelas  in  the  child  is  similar  to  that  in  the 
adult,  excepting  in  the  new-born  or  very  young  infant.  Generally,  however, 


714  TEXT-BOOK  OF  PEDIATRICS 

it  is  relatively  mild  and  benign.  The  initial  chill,  frequently  noted  in  adults-, 
is  usually  wanting  in  young  children.  The  general  health  is  often  not 
markedly  disturbed,  even  when  the  local  manifestations  are  distinct.  Albu- 
minuria  may  be  expected,  but  true  nephritis  is  rare. 

In  anemic  and  feeble  children  the  local  expression  is  often  slight.  The 
redness  may  be  very  indistinct  and  the  marginal  elevation  small;  so  that, 
in  the  absence  of  these  characteristic  features,  the  eruption  is  discernible 
by  palpation  rather  than  by  sight.  Severe  forms  are  much  less  frequent 
than  in  adults.  When  they  do  occur,  they  commonly  involve  an  extensive 
area  of  the  skin,  a  high  fever,  great  restlessness,  delirium,  somnolence,  and 
possibly,  death  within  a  few  days. 

The  enlargement  of  the  spleen  is  usually  very  marked  but  difficult  of 
palpation  on  account  of  its  softness.  The  blood  shows  a  distinct  leucocytosis. 

The  fever  may  be  entirely  wanting  in  young  and  cachectic  children. 
The  small  frequent  pulse  and  the  general  prostration  indicate,  nevertheless, 
the  severity  of  the  disease. 

Complications. — The  most  frequent  complication,  especially  in  young 
and  rickitic  children,  is  broncho-pneumonia.  As  in  old  people  this  is  often 
the  direct  cause  of  death.  Excepting  in  the  new-born  and  in  weakly  infants, 
general  sepsis  is  rare.  Sometimes  a  widespread  post-erysipelatous  edema 
develops  after  the  erysipelas  has  disappeared.  This  occurs  most  frequently 
on  the  limbs  and  may  have  an  independent  distribution.  Subcutaneous  ab- 
scesses are  common  sequelae. 

Relapses  are  fairly  common  in  older  children.  Individuals  with  chronic 
eczema,  rhinitis,  blepharitis,  etc.,  are  especially  predisposed  to  the  disease. 

Erysipelas  of  the  new-born  is  hardly  ever  congenital,  even  in  children 
born  of  septic  mothers.  Under  these  circumstances  general  sepsis  in  the 
infant  is  more  common.  Erysipelas  of  the  pregnant  mother  often  causes 
abortion  or  premature  labor.  The  viable  infant,  in  such  an  event,  is  rarely 
infected.  Usually  erysipelatous  infection  does  not  occur  until  after  birth. 
The  common  route  of  infection  is  by  way.  of  the  umbilical  wound,  which 
has  been  subject  to  neglect  and  want  of  cleanliness.  Formerly,  in  the  old 
type  of  lying-in  hospitals  all  sorts  of  umbilical  infection  resulting  in  ulcer, 
lymphangitis,  periumbilical  phlegmon,  and  general  sepsis  were  common 
occurrences.  Premature  and  debilitated  infants  have  the  greatest  liability 
to  infection.  The  disease  is  discussed  in  its  clinical  relations  on  page  149. 

The  diagnosis  is  usually  easy.  Difficulties  are  most  likely  to  arise  in 
its  differentiation  from  acute  eczema  of  the  face,  phlegmon,  and  lymphan- 
gitis, but  in  none  of  these  disorders  do  we  find  the  characteristic  raised 
margin.  The  doubt  will  ordinarily  be  cleared  up  by  the  second  or  third 
day;  but  there  are  true  intercurrent  forms  of  erysipelas  and  phlegmon, 
occurring  commonly  on  the  scalp.  The  prognosis,  in  strong  healthy  infants 
or  in  older  children,  is  better,  as  a  rule,  than  in  the  adult.  In  the  new-born, 
in  whom  erysipelas  often  appears  as  a  feature  of  general  sepsis,  the  progno- 
sis is  nearly  always  bad.  This  is  equally  true  of  feeble,  artificially-fed 
infants  during  the  first  months. 


THE  ACUTE  INFECTIOUS  DISEASES  715 

Prophylaxis  depends  upon  the  protection  of  the  new-born  by  efficient 
asepsis  and  antisepsis.  The  isolation  of  a  person  suffering  with  erysipelas 
in  the  home  is  necessaiy  when  a  new-born  infant,  a  recently  delivered 
mother,  or  any  member  of  the  family  with  a  recent  wound  is  in  the  house. 
In  the  hospital,  isolation,  even  from  the  medical  wards,  should  be  complete. 

Treatment. — If  the  disease  attacks  the  artificially-fed  infant  or  the 
new-born,  every  effort  must  be  made  to  procure  mother's  milk.  Without 
this  there  is  hardly  any  hope  for  the  new-born  babe.  In  infancy,  and  even 
with  older  but  feeble  children,  local  applications  of  ice  are  contraindicated. 
The  painting  of  the  surface  with  a  twenty-five  per  cent,  mixture  of  ichthyol 
with  vaseline  or  collodium,  and  the  use  of  compresses  moistened  in  a  solu- 
tion of  aluminum  acetate  are  recommended.  Camphophenique  may  be 
applied  with  a  brush  once  to  twice  daily.  The  use  of  ultra-violet  rays, 
also  injections  of  polyvalent  antistreptococcic  serum  are  recommended. 


Under  this  caption  it  will  be  desirable  briefly  to  discuss  the  septicemic 
diseases  with  reference  to  their  special  significance  and  peculiarities  in 
childhood,  although  the  details  are  considered  in  several  divisions  of  this  work. 

Fortunately  the  time  has  passed  when  the  majority  of  new-born  in- 
fants in  lying-in  hospitals  and  foundling  homes  succumbed  to  puerperal 
fever.  Nevertheless,  even  to-day,  septic  disease  in  infancy  is  not  a  rar- 
ity and  is  frequent  in  direct  ratio  to  the  youth  of  the  child,  so  that  it  is 
most  frequently  met  with  in  the  new-born  and  in  young  infants.  In 
these  children  the  symptomatology  of  sepsis  presents  a  number  of  peculi- 
arities, the  special  consideration  of  which  is  desirable.  The  sepsis  of  the 
new-born  which  is  consequent  upon  puerperal  infection  in  the  mother, 
and  septicemia  resulting  from  umbilical  infection  are  not  included  in  this 
discussion  (see  page  144). 

The  causative  bacteria  of  sepsis  in  children  are  the  ordinary  pyogenic 
bacteria  and  chief  among  them  are  the  streptococci,  and  particularly  cer- 
tain intestinal  organisms.  Relatively  frequent  is  the  colon  bacillus,  the 
pneumococcus,  the  staphylococcus,  the  bacillus  of  influenza,  etc. 

The  frequency  of  the  septic  affections  in  early  childhood  is  partly  ex- 
plained by  the  fact  that  the  ordinary  ports  of  entry — the  skin  and  the  mu- 
cous membranes,  are  more  delicate  and  more  easily  injured  than  they  are 
in  older  children  or  in  adults.  The  tender  thin  epidermis  is  frequently 
the  seat  of  fissures,  erosions,  intertrigo  and  eczema,  in  which  the  organisms 
producing  sepsis  readily  find  a  fertile  soil,  and  all  the  more  fertile  when  its 
proper  care  and  cleanliness  are  neglected.  The  organisms  cause  abscesses, 
ulcers,  phlegmon,  etc.,  which,  often  small  and  comparatively  unimportant 
in  themselves,  nevertheless  may  serve  as  the  focus  of  a  fatal  general  infec- 
tion. Similarly  such  a  result  may  follow  from  small  multiple  abscesses 
which  appear  numerously  in  the  skin  of  the  occiput,  the  back  and  the  nates 
of  infants  suffering  with  disturbances  of  nutrition.  Very  often  the  mucous 
membranes,  imperfectly  developed,  permit  the  easy  entrance  of  infective 
organisms  to  an  extent  uncommon  after  infancy  and  altogether  unknown 


716  TEXT-BOOK  OF  PEDIATRICS 

in  the  adult.  The  permeability  of  the  delicate  epithelium  of  the  mouth  is 
increased  by  stomatitis,  thrush,  etc.  The  well-intentioned  but  thoughtless 
scrubbing  of  the  mouth  of  the  infant  which,  unfortunately,  is  still  practiced 
to  a  great  extent,  increases  the  injury  to  the  delicate  mucosa  and  opens 
wide  the  door  to  invading  organisms.  Similarly,  Bednar's  aphthae,  often 
covered  by  a  fibrinous  pseudodiphtheritic  exudate,  or  an  inflamed  nasal 
mucosa,  as  in  syphilitic  rhinitis,  or  adenoid  growths,  give  easy  access  to  the 
invaders.  The  tonsils,  which  play  an  important  part  in  later  years,  are 
comparatively  harmless  in  infancy;  in  lact,  all  forms  of  tonsillitis  are  rare 
at  this  age.  The  pulmonary  affections,  so  often  found  at  autopsy,  following 
pyemia,  and  sometimes  demonstrable  during  life,  must  usually  be  consid- 
ered as  of  secondary  relation.  While  the  intestinal  epithelium  of  the  new- 
born is  permeable  to  bacteria  and  to  proteins,  and  while  its  permeability 
may  be  increased  by  the  injuries  worked  by  a  number  of  intestinal  disor- 
ders, we  do  not  know  what  relation  the  normal  and  abnormal  factors  bear 
to  each  other.  It  is  certain,  however,  that  among  these  forms  of  intestinal 
disease,  a  streptococcic  colitis  often  leads  to  general  sepsis. 

A  very  important  port  of  entry  is  opened  in  the  urinary  tract  by  cysto- 
pyelitis  (see  page  439).  This  disorder  is  extremely  common  among  young 
infants  and  must  be  looked  for  in  all  cases  of  fever  of  indefinite  origin.  In 
infancy,  a  sepsis  from  colon  bacillus  infection  often  arises  from  this  source, 
or,  to  be  more  exact,  occurs  coincidently  with  it ;  since,  obviously,  a  cysti- 
tis due  to  the  colon  bacillus  must  be  considered  as  a  probable  metastasis 
from  the  blood  infection.  These  infections  are  not  infrequently  the  result 
of  an  alimentary  intoxication. 

The  tendency  of  infancy  to  septic  disease  depends,  in  part,  upon  an 
initial  want  of  protective  bodies  in  the  blood  and,  partly,  upon  the  inability 
to  form  them,  in  reaction  to  the  infective  organism.  This  inability  is  espe- 
cially marked  in  artificially-fed  children,  while  the  breast-fed  infant  is 
always  better  protected  (Moro).  In  the  artificially-fed,  frequent  and 
exhausting  disturbances  of  nutrition  favor  the  infection.  The  significance 
of  these  influences  can  hardly  be  over-estimated.  The  number  of  breast- 
fed infants  with  sepsis  is  extremely  small,  if  cases  occurring  in  the  new-born 
in  poorly  conducted  lying-in  hospitals  be  excepted.  Furthermore,  prema- 
ture and  syphilitic  infants  show  special  tendencies  to  septic  infection.  In 
this  connection,  the  reader  is  referred  to  the  chapter  upon  Sepsis  of  the 
New-born  (see  page  144). 

The  bacterial  diseases  of  infancy  are  peculiar  in  their  very  acute  course, 
their  rapid  progress,  their  active  spread  to  many  organs,  and  their  tendency 
to  general  infection.  This  tendency  to  wide  distribution  is  seen,  also,  in 
other  diseases  which,  in  the  narrow  sense,  are  not  of  septic  character,  as, 
for  instance,  tuberculosis  and  syphilis.  Similarly,  with  typhoid  fever  in 
the  infant,  the  phenomena  of  general  infection  are  more  conspicuous  and 
the  local  or  intestinal  manifestations  less  so  than  in  the  adult.  The  pneu- 
mococcus  shows  a  peculiar  tendency  in  childhood,  and  especially  during 
the  first  two  or  three  years,  to  widespread  metastases  and  to  the  develop- 
ment of  suppuration. 


THE  ACUTE  INFECTIOUS  DISEASES  717 

The  course  of  sepsis  is  often  a  turbulent  one.  Following  a  comparatively 
mild  onset,  extremely  threatening  symptoms  of  severe  infection  or  intoxica- 
tion suddenly  appear,  often  leading  to  collapse  and  death  with  surprising 
rapidity.  This  swift  course  is  responsible  for  the  fact  that  far  less  frequently, 
than  in  later  years,  does  the  development  of  the  disease  give  sufficient  time 
for  the  formation  of  distinct  pyemic  metastases.  These  are  most  often  seen 
in  the  slower  progress  of  pneumococcic  sepsis.  The  low  resistance  of  the 
infant  is  responsible  for  the  frequent  rupture  of  the  primary  focus  of  infec- 
tion into  the  circulation,  undelayed  by  an  interposed  lymphadenitis. 

In  the  symptom-complex  of  sepsis,  the  rapid  toxic  action  is  reflected  in 
the  general  condition  by  an  apathy,  alternating  with  restlessness,  jactita- 
tion and  tremor.  The  anxious  expression,  the  sunken  eyes,  and  the  sharp- 
pointed  nose  indicate  the  severity  of  the  disease.  In  the  infant  a  general 
hypertonicity  of  the  musculature  is  often  observed.  Convulsions  without 
cerebral  infection  or  septic  meningitis  are  rare. 

The  fever  is  irregular  and  remittent,  but  is  hardly  ever  absent  at  the 
onset  of  the  attack.  Later,  however,  collapse,  suddenly  appearing,  may 
bring  the  temperature  down  to  a  normal  or  subnormal  range;  a  result  which 
is  more  common  in  general  sepsis  than  it  is  when  pyemic  foci  exist. 

Chills  seldom  occur;  in  fact,  this  symptom  is  scarcely  ever  seen  under 
any  condition  in  small  children. 

The  pulse  is  always  small  and  extraordinarily  rapid.  Cyanosis  and 
coldness  of  the  extremities  are  common.  The  heart  rarely  gives  any  clinical 
evidence  of  organic  change.  Ulcerative  endocarditis,  which  in  the  septic 
adult  is  of  so  frequent  development  that  it  may  be  considered  the  most 
important  symptom,  is  only  exceptionally  found  in  young  children.  This 
is  equally  true  of  simple  endocarditis.  Fibrino-purulent  pericarditis  is  more 
common  and  is  usually  either  the  accompaniment  or  the  result  of  a  pleural 
empyema.  The  diagnosis  of  pericarditis  (see  page  409),  is  seldom  clinically 
possible.  The  dyspnoea  and  cyanosis  would  tend  to  arouse  a  suspicion  of 
pneumonia  or  miliary  tuberculosis. 

In  infantile  sepsis  certain  groups  of  symptoms,  and  particularly  those 
of  the  air  passages,  the  gastro-intestinal  tract,  or  of  the  skin,  may  dominate 
the  disease-picture  so  completely,  that  the  physician  easily  falls  into  the 
error  of  their  exclusive  diagnosis,  while  he  overlooks  the  basic  disease. 

Oftentimes  respiration  acquires  a  toxic  type  and  suggests  an  immediate 
diagnosis  of  pneumonia  in  spite  of  the  failure  to  demonstrate  any  signs  of 
infiltration  by  physical  examination.  A  distressing  dyspnoea  may  be  mis- 
leading, but  the  definitely  deepened  respirations,  the  slight  participation  of 
the  auxiliary  muscles,  and  the  coolness  of  the  expired  air,  conditions  not 
proper  to  pneumonia,  will  aid  the  clinician  in  reaching  a  correct  diagnosis. 

Septic  disease  is  much  more  readily  mistaken  for  severe  gastro-intestinal 
disorders,  especially  in  young  infants,  since  vomiting  and  diarrhoea  may  be 
major  symptoms.  It  must  be  admitted  that  as  yet  we  do  not  know  how 
frequently  the  primary  focus  of  sepsis  may  lie  in  the  digestive  tract  itself,  or 
to  what  extent  gastro-intestinal  disturbances  may  appear  as  merely  the 
toxic  symptoms  of  a  sepsis  arising  in  some  other  part  of  the  body.  It  may 


718  TEXT-BOOK  OF  PEDIATRICS 

only  be  said  that  in  a  majority  of  instances  the  gastro-intestinal  symptoms 
are  secondary  to  the  sepsis.  Since  cases  of  severe  streptococcic  infection  of 
the  bowel,  producing  liberation  and  sanguino-purulent  stools,  do  occur,  it 
must  be  admitted  that  a  true  primary  intestinal  sepsis  may  exist.  When 
neither  primary  nor  metastatic  foci  can  be  found,  the  real  causative  agent 
may  be  hard  to  discover.  This  is  particularly  true  when  icterus  and  cuta- 
neous hemorrhages,  which  are  characteristic  of  sepsis  and  are  not  associated 
with  primary  gastro-intestinal  disease,  fail  to  appear. 

The  spleen,  as  a  rule,  is  markedly  enlarged  but  is  often  impalpable,  on 
account  of  its  softness.  Enlargement  of  the  liver  is  so  common  a  symptom 
in  infancy  that  no  conclusions  can  be  drawn  from  it  alone,  but  if  it  is  accom- 
panied by  icterus,  fever  and  serious  disturbance  of  the  general  health,  the 
possibility  of  sepsis  must  always  be  considered.  Nephritis  of  variable  degree 
is  of  very  constant  occurrence. 

The  skin  is  very  commonly  involved.  Primarily,  an  erythema  of  vary- 
ing form,  scarlatinal,  rubeolar,  or  urticaria!,  usually  appears.  No  great 
significance  can  be  attached  to  this  since  it  occurs  in  innumerable  minor 
diseases,  in  intestinal  disturbances,  etc.  Vesicular,  pustular,  or  pemphigoid 
eruptions,  however,  are  more  serious  and  more  suggestive  of  sepsis.  Cuta- 
neous hemorrhages  are  of  very  grave  importance.  They  are  extremely 
common  in  sepsis  and  are  rarely  seen  in  infancy  under  other  than  septic 
conditions.  They  are  considered  to  be  due  to  capillary  bacterial  emboli. 
They  vary  in  size  and  number.  Often  no  larger  than  a  pinhead,  they  may 
extend,  in  some  cases,  with  frightful  rapidity,  to  include  large  areas.  Fre- 
quently these  hemorrhages  are  not  of  altogether  spontaneous  occurrence, 
but  arise  in  areas  of  the  skin  exposed  to  slight  pressure,  as  over  the  patellar 
ligament,  after  tapping  with  the  pleximeter  for  the  knee  reflex,  or  at  the 
site  of  camphor  injections,  etc.  Their  significance  under  such  circumstances 
is  not  diminished,  for  they  often  give  the  first  signs  of  sepsis. 

Hemorrhages  from  the  mucous  membranes  of  the  conjunctiva,  the  nose, 
the  stomach,  or  the  intestinal  tract,  frequently  occur.  At  times  these 
hemorrhages,  whether  in  the  skin  or  from  the  mucous  membranes,  or  simul- 
taneously from  both,  so  govern  the  entire  clinical  picture  that  the 
inexperienced  observer  is  likely  to  make  a  diagnosis  of  primary  hemor- 
rhagic  diathesis.  The  benign  forms,  however,  of  the  purpura  of  Werlhof  are 
extremely  uncommon  during  the  first  year.  In  the  very  nature  of  the  con- 
dition a  distinct  differential  diagnosis  is  often  impossible,  since  many 
cases  of  hemorrhagic  diathesis  are  of  bacterial  origin.  Nevertheless,  careful 
observation  in  most  of  the  septic  forms  soon  reveals  their  true  character, 
either  by  the  consequent  disturbance  of  the  general  health,  by  the  develop- 
ment of  icterus,  nephritis,  etc.,  or  by  the  clear  indication  of  a  primary  focus 
of  infection.  In  later  infancy  and  in  older  children,  cutaneous  hemorrhages 
occasionally  appear  under  conditions  of  atrophy  or  chronic  disturbance  of 
nutrition.  These  usually  appear  in  the  skin  of  the  abdomen.  They  must 
be  regarded,  in  all  probability,  as  an  expression  of  injury  to  the  vessel  walls, 
which  is  susceptible  of  recovery. 


THE  ACUTE  INFECTIOUS  DISEASES  719 

The  diagnosis  of  sepsis  often  meets  with  great  difficulties,  when  no 
distinct  port  of  entry,  no  primary  focus,  and  no  metastases  can  be  found. 
The  demonstration  of  bacteria  in  the  blood  is  extremely  difficult  in  infants, 
from  whom  it  is  hard  to  get  sufficient  blood  for  examination.  Then,  too, 
bacteriemia  is  not  synonymous  with  sepsis.  In  even  mild  cases  of  lobar 
pneumonia,  for  instance,  it  is  nearly  always  possible  to  obtain  a  culture  of 
pneumococci  upon  proper  media.  Clinically,  severe  gastro-intestinal  dis- 
orders often  resemble  sepsis  in  many  respects.  In  such  cases,  differentia- 
tion is  readily  made  if  cutaneous  hemorrhages  and  icterus  appear. 

The  prognosis  is  generally  bad.  In  advanced  infancy  it  is  not  entirely 
hopeless.  Pneumococcic  sepsis  is  the  most  favorable  form  and  recovery 
from  it  may  take  place  in  spite  of  numerous  bone  and  joint  metastases. 

Prophylaxis  accomplishes  much  more  than  treatment.  Scrupulous  care 
and  extreme  cleanliness  give  great  protection  to  the  young  infant.  Breast 
feeding  must  be  considered  the  best  prophylactic  and  the  best  remedy. 
Artificially-fed  infants  with  disturbances  of  nutrition  succumb  rapidly. 
The  smallest  rhagades,  or  the  most  minute  pustular  eruption  demand  care- 
ful or  antiseptic  treatment. 

Treatment. — Up  to  the  present  time  the  only  treatment  for  developed 
sepsis  is  symptomatic,  since  no  specific  serum  therapy  can  yet  be  said  to 
give  any  certain  results.  Abscesses  must  be  opened  as  soon  as  possible. 
Hemorrhages  are  often  entirely  beyond  control  a  characteristic,  indeed,  of 
the  hemorrhages  of  sepsis.  For  epistaxis  of  long  duration  tampons  should 
be  used.  Recently,  coagulin  has  been  employed.  Some  clinicians  recom- 
mend non-specific  protein  shock  therapy.  In  persistent  anorexia  very 
concentrated  food  should  be  given.  For  further  details  consult  the  para- 
graph dealing  with  the  Treatment  of  Hemorrhagic  Diathesis  Page  190.  Ex- 
ternal hemorrhages  may  be  treated  by  compression,  by  applications  of 
gelatin,  or  by  the  galvano-cautery.  The  subcutaneous  injection  of  10  to  20 
c.c.  (H-%  ounces),  of  a  10  per  cent,  sterilized  solution  of  gelatin,  may 
be  tried.  In  gastro-intestinal  hemorrhage,  gelatin  may  be  given  internally. 
Liquor  f  erri  chloridi  may  also  be  used  in  doses  of  two  or  three  drops,  in  milk 
or  gruel,  every  few  hours. 


IX. 
TUBERCULOSIS 

BY 

C.  Frh.  von  PIRQUET, 

Vienna. 

REVISED  AND  EDITED  BY 
HENRY  DIETRICH,  M.D., 

Attending  Pediatrician  Children's  Hospital,  Los  Angeles,  Calif. 

AT  one  time  tuberculosis  was  looked  upon  as  essentially  a  disease  of 
adults,  because  the  cavernous  pulmonary  phthisis  or  consumption  was  sup- 
posed to  be  its  main  form.  Not  until  Koch  discovered  the  tubercle  bacillus 
in  1882  and  showed  that  a  large  number  of  diseases  of  different  systems  of 
organs  were  due  to  this  same  organism  did  the  clinical  conception  of  tuber- 
culosis begin  to  embrace  a  much  larger  field.  In  recent  years  it  has  been 
shown,  by  careful  postmortem  study  and  by  the  use  of  the  local  tuberculin 
reaction,  that  tuberculosis  not  only  occurs  frequently  in  childhood,  but  that 
it  is  the  most  important  chronic  disease  among  the  children  of  the  wage- 
working  classes  of  the  great  cities. 

In  the  large  majority  of  cases,  the  causative  organism  is  the  human  type 
of  the  tubercle  bacillus.  In  but  a  very  small  per  cent,  is  the  bovine  type  of 
bacillus  demonstrable.  Furthermore,  the  latter  does  not  produce  so  severe  a 
form  of  disease  as  does  the  human  type. 

Every  human  being  is  probably  predisposed  to  tuberculosis  in  the  sense 
that  infection  with  virulent  tubercle  bacilli  causes  disease.  An  individual 
difference  of  predisposition  may  lie  in  the  fact  that  the  same  infection  may 
produce  disease  of  greater  degree  of  severity  and  destructiveness  in  one 
person  than  another.  In  this  respect  the  age  at  which  the  infection  occurs  is 
especially  significant.  It  is  the  more  dangerous  the  earlier  its  invasion  in 
childhood.  For  this  reason  alone  the  hereditary  transmission  of  tuberculosis 
is  a  matter  of  little  inportance  in  later  life.  Children  infected  during  fetal 
life,  die  during  the  early  months  of  infancy.  Such  transmission  in  utero  is 
extremely  rare.  Indeed,  it  hardly  needs  to  be  considered  from  a  practical 
standpoint.  Infection  from  a  tuberculous  placenta  during  birth,  which  is 
accepted  by  Rietschel.  may  occur  in  some  of  the  cases  that  die  during  the 
first  year  of  life.  Prolonged  latency  of  such  an  infection,  causing  tuberculosis 
at  a  later  period  of  life  (Baumgarten)  is  not  probable,  even  though,  accord- 
ing to  Bartel's  findings,  it  cannot  be  wholly  excluded. 

Since  it  is  clearly  shown  by  a  comparison  of  autopsy  records  with  the 
history  of  tuberculin  reactions  that  the  frequency  of  tuberculosis  in  child- 
hood increases  from  year  to  year,  coincidently  with  the  percentage  of 
children  who  have  survived  acute  infectious  disease,  it  seems  quite  evident 
720 


TUBERCULOSIS  721 

that  the  tuberculous  infection  is  not  congenitally  transmitted,  but  is  ac- 
quired from  external  sources  in  later  life.  During  the  last  few  years  there 
has  been  much  discussion  concerning  the  mode  of  infection.  Certain  it  is 
that  the  first  manifestations  are  nearly  always  to  be  found  in  the  lungs  and 
bronchial  lymph  nodes.  Since  the  regional  lymph  nodes  are  always  the 
first  to  become  diseased  in  infections  of  the  skin  (Cornet),  we  may  accept 
the  simplest  explanation  that  in  disease  of  the  bronchial  glands,  also,  the 
infection  comes  from  the  lung.  The  tubercle  bacilli  have  probably  reached 
the  lung  by  the  inhalation  of  droplets  containing  them  (Fliigge) .  From  the 
reports  of  Parrot  (1876),  Kiiss  (1898),  Albrecht  (1909),  and  especially  from 
the  excellent  studies  of  Ghon  (1912),  we  know  that  in  carefully  made  autop- 
sies of  tuberculous  children  a  port  of  entry,  a  primary  lesion,  can  always  be 
found.  In  the  great  majority  of  cases  this  primary  focus  lies  in  the  lung  and 
most  commonly  not  in  the  apex  but  in  various  other  parts. 

In  several  cases  in  which  the  primary  focus  was  in  the  lungs,  Ghon  found 
the  various  lobes  affected  as  follows:  upper  right  lobe,  fifty-seven  times; 
middle  right  lobe,  fourteen  times;  lower  right  lobe,  thirty-nine  times;  upper 
left  lobe,  fifty  times;  and  the  lower  left  lobe,  forty  times.  In  other  words, 
the  frequency  of  the  primary  affection  in  the  various  lobes  corresponds  to 
the  size  of  the  lobe. 

According  to  Heinrich  Albrecht,  the  primary  lesion  in  the  lung  varies  in 
size  from  that  of  a  millet-seed  to  that  of  a  hazel-nut.  It  is  a  round  focus  and 
shows  a  small  fissure  at  the  centre  corresponding  to  the  line  of  the  bronchiole. 
The  focus  is  usually  isolated.  More  rarely,  several  foci  are  found  in  the 
same  lung  or  in  both  lungs.  The  centre  is  at  first  caseated ;  later  it  goes  on  to 
sclerosis  and  subsequent  calcification  or  fibrous  contraction  which  usually 
begins  by  encapsulation  at  the  outer  margin.  Finally,  the  focus  may  be 
reduced  to  a  small  scar  with  a  granular  particle  of  calcium  salt  at  its  centre 
and  can  be  found  only  by  extremely  careful  examination  of  the  entire  lung. 
In  other  cases,  the  focus  does  not  heal  and  a  small  cavity  communicating 
with  a  bronchus  is  formed.  Miliary  nodules,  which  gradually  enlarge,  ap- 
pear around  it. 

The  tubercle  bacilli  may,  however,  invade  the  body  by  some  other 
route.  The  frequency  of  primary  infection  of  the  gastro-intestinal  tract  has 
been  much  debated.  It  seems  that  such  mode  of  infection  is  more  common 
among  infants  in  countries  where  cow's  milk  is  fed  without  boiling,  as  in 
England  or  America. 

In  the  carefully  conducted  autopsies  made  by  Albrecht  and  Ghon.  of 
Vienna,  very  few  definite  primary  foci  in  the  intestine  were  observed.  In 
1060  autopsies  on  tuberculous  children,  Albrecht  found  but  seven  with  pri- 
mary intestinal  tuberculosis.  Ghon  found  three  in  189  cases. 

Other  mucous  membranes  and  the  skin,  also,  may  occasionally  serve  as 
a  port  of  entry  for  the  tubercle  bacillus.  As  compared,  however,  with  pri- 
mary lung  infections  these  cases  are  extremely  rare. 

In  his  series,  Albrecht  found  one  primary  focus  in  the  nose,  one  in  the 
mucous  membrane  of  the  cheek  and  one  in  the  tonsil.    Ghon,  in  his  series, 
found  one  primary  focus  in  the  skin  and  one  in  the  tonsil. 
46 


722  TEXT-BOOK  OF  PEDIATRICS 

The  spread  of  tuberculosis  from  the  primary  lesion  to  the  regional  nodes, 
occurs  by  way  of  the  lymph  channels.  The  small  nodes  at  the  bronchial 
branches  and  the  nodes  at  the  bifurcation  of  the  trachea,  enlarge  and  caseate, 
From  these  the  infection  spreads  to  the  nodes  lying  along  the  trachea. 

With  this  course  the  spread  of  the  process  of  infection  in  late  childhood 
usually  terminates.  In  early  childhood,  however,  a  further  spread  from  the 
primary  focus  to  the  surrounding  tissue  commonly  occurs.  The  focus  en- 
larges in  all  directions,  reaches  the  pleura,  where  it  causes  serofibrinous  in- 
flammation, and  finally  occupies  an  entire  lobe,  which  may  become  cavernous. 

The  bacilli  from  the  primary  focus  having  reached  the  bronchi,  extend 
from  there  to  the  mouth,  nose  and  conjunctiva  and  infect  the  regional  lymph 
nodes  of  these  parts.  From  the  mouth  and  pharynx  the  bacilli  are  swal- 
lowed and  reaching  the  intestine  develop  intestinal  ulcers,  caseation  of  the 
mesenteric  nodes  and  peritonitis. 

Distribution  by  way  of  the  blood  is  especially  dangerous  to  life.  This 
occurs  when  a  large  number  of  bacilli  reach  the  blood  from  the  primary  focus 
directly  or  by  rupture  of  a  caseated  node  into  a  vein  and  are  thus  spread 
broadcast  over  the  body.  The  tendency  of  the  infection  to  spread  by  the 
blood  channels  decreases  from  year  to  year.  This  is  indicated  by  the  statis- 
tics of  tuberculous  meningitis,  which  is  most  frequent  at  the  end  of  the 
first  year. 

In  the  large  study  of  the  disease,  however,  we  must  not  consider  the 
parasite  alone  as  though  it  were  the  only  factor  controlling  the  situation. 
As  a  result  of  the  infection,  an  allergy — a  change  in  the  reactive  power  of 
the  organism,  occurs.  Specific  substances  of  the  nature  of  antibodies,  or 
ergines,  which  have  a  digestive  action  upon  the  parasite  are  formed.  The 
products  of  this  digestion  seem  to  be  the  cause  of  such  effects  upon  the 
general  organism  as  fever,  etc.  They  probably  also  cause  the  manifestations 
of  inflammation  around  the  tuberculous  focus,  as  well  as  the  scrofulous 
catarrh  of  the  mucous  membranes.  In  the  acute  diseases,  such  as  chicken- 
pox  and  measles,  we  may  suppose  a  similar  formation  of  antibodies  which 
digest  the  infective  organisms  and  thus  form  substances  causing  the  inflam- 
matory conditions.  In  the  latter  infections,  however,  the  digestion  destroys 
all  the  invaders  and  the  disease  ends  with  crisis.  In  tuberculosis,  on  the 
contrary,  all  the  micro-organisms  are  not  destroyed.  The  bacilli  at  the 
centre  of  the  foci  remain  alive  and  are  merely  encapsulated.  If  occasion 
arises  they  may  again  get  into  the  circulation  and  cause  new  foci. 

The  opportunity  for  reinfection  is  also  afforded  in  another  way;  when 
the  antibodies  become,  for  some  reason,  inactive  and  the  bacteria  get  be- 
yond their  power.  This  may  occur  in  such  anergic  periods  as  are  observed 
during  measles.  In  this  disease  a  reduction  of  the  intensity  of  the  tubercu- 
lin reaction  always  takes  place  when  the  rash  appears.  For  about  a  week 
the  reaction  power  is  reduced  to  a  minimum,  after  which  it  gradually  reap- 
pears. Clinical  experience  shows  that  tuberculosis  frequently  spreads  very 
rapidly  at  this  time.  It  is  probable  that  other  acute  infectious  diseases  act 
in  a  similar  manner  and  that  disturbances  of  other  kinds,  such  as  pregnancy, 
or  underfeeding,  hard  work  and  the  like,  may  have  similar  effects. 


TUBERCULOSIS 


723 


Chronic  cavernous  pulmonary  phthisis,  rare  in  early  childhood,  but  the 
most  important  form  of  tuberculosis  in  later  life,  may  probably  be  traced 
back  to  latent  tuberculosis,  acquired  early  (Behring,  Hamburger,  Romer) ; 
especially  since  animal  experiments  have  proved  that  an  intravenous  in- 
jection of  tubercle  bacilli,  obtained  from  the  animal  itself,  results  in  cavity 
formation  (Romer). 

According  to  F.  Hamburger,  we  must  recognize  three  distinct  stages  of 
tuberculosis:  (1)  The  primary  lesion  with  infection  of  the  regional  lymph 
nodes  and  the  surrounding  tissue.  This  may  mark  the  termination  of  the 
disease;  or  (2)  a  secondary  stage  with  hematogenous  and  lymphogenous  ex- 
tension to  the  various  organs  may  be  added.  Finally,  after  years  (3)  the 
tertiary  stage,  manifested  chiefly  by  cavity  formation  in  the  lungs,  sets  in. 

The  Frequency  of  Tuberculosis. — As  a  result  of  its  irregular  distribution 
and  the  variable  character  of  the  disease  at  successive  periods  of  life,  we  get 
very  different  views  of  its  frequency,  according  as  these  are  based  upon 
statistics  derived  from  the  death  record,  from  the  clinical  history,  from  the 
autopsy  findings,  or  from  the  results  of  tuberculin  reactions. 

The  deaths  from  tuberculosis  are  at  a  maximum  during  the  first  year, 
as  a  consequence  of  the  low  resistance  of  the  child  at  this  age.  They  are 
infrequent  during  the  rest  of  childhood  until  puberty  approaches,  when  the 
number  again  increases  as  a  result  of  the  development  of  the  pulmonary 
form.  Thus,  for  instance,  the  statistics  of  the  United  States  for  the  year 
1900  show  the  following  death  record  from  consumption  for  successive  age- 
periods  of  five  years. 


Age     0       5       10      15      20       25        30        35        40      45      50      55      60      65      70      75      80    100 


Deaths 


39 


11 


17 


71 


137 


154 


133 


114 


82 


57 


40 


31 


10 


11 


Cornet  properly  emphasizes  the  fact  that  this  statistical  viewpoint  is 
one-sided.  A  better  comparison  is  secured  if  the  number  of  deaths  is  com- 
pared with  the  number  surviving  of  the  age  under  consideration. 

In  Prussia,  the  average  for  sixteen  years  shows  that  the  numbers  of 
deaths  per  10,000  at  each  age  were  as  follows :  (Cornet) — • 


Age 


15 


Boys 
Girls 

23 
26 

21 

21 

12 
14 

6.9 
8.0 

4.5 
6.0 

4.9 
8.9 

From  this  table  it  is  seen  that  the  first  high  figures  rapidly  fall  during 
childhood.  Among  boys,  the  minimum  rate  is  reached  at  about  the  tenth 
year.  For  girls,  the  figures  are  low  during  the  first  year  and  higher  than 
those  for  boys  during  middle  childhood.  Later,  women  are  at  first  chiefly 


724 


TEXT-BOOK  OF  PEDIATRICS 


involved  in  the  increase  caused  by  pulmonary  tuberculosis,  but  in  a  short 
time  the  death-rate  among  men  surpasses  it  to  a  marked  degree. 


Age 


15   20   25   30   40   50   63   70   80   100 


Men 

18 

32 

37 

44 

55 

76 

100 
68 

69 
46 

26 
20 

Women 

20 

25 

33 

38 

38 

50 

According  to  the  clinical  manifestations,  on  the  contrary,  the  middle 
years  of  childhood  are  much  more  actively  involved,  since  the  numerous 
exhibitions  of  the  secondary  stage  of  the  disease  (glandular,  bone  and  joint 
tuberculosis),  which  are  not  fatal,  appear  at  this  time. 

Statistics  of  clinical  manifestations  are  hard  to  obtain,  since  they 
depend  too  much  upon  the  subjective  consideration  of  the  case.  The  figures 
are  extremely  variable  and  include  numerous  cases  of  indefinite  diagnosis. 

The  results  of  autopsies,  on  the  contrary,  are  extremely  valuable  if,  as 
Ghon  and  Albrecht  have  done,  the  greatest  pains  are  taken  to  find  even  the 
minutest  tuberculous  changes  in  the  lungs  and  lymph  nodes. 

These  reports  show  an  increasing  progress  of  tuberculosis  from  the 
first  year: 


Age 


10 


14 


Percentage  of  tu- 

berculosis   at    au- 

15 

40 

60 

56 

63 

70 

topsy,   at  various 
ages   (F.  Hamburger.) 

This  form  of  investigation  does  not,  however,  give  an  idea  of  the  fre- 
quency of  tuberculosis  in  general,  since  in  some  of  the  cases,  tuberculosis  has 
been  the  cause  of  death;  in  others,  it  has  been  but  a  secondary  cause;  while 
in  still  others,  it  is  but  a  minor  part  of  the  findings. 

The  frequency  of  tuberculosis  among  apparently  healthy  children  may 
be  determined  by  the  tuberculin  reaction.  In  Vienna,  Hamburger  and 
Monti  obtained  the  following  figures  from  the  results  of  the  careful  applica- 
tion of  the  tuberculin  reaction  in  509  children  who  showed  no  clinical  signs 
of  tuberculosis: 


Age  in  years       0 


10       11        12        13      14 


Percentage  of 
positive  reaction 


20 


32 


52 


51 


61 


73 


71 


93 

95 

94 

85  93  95  94  94 


From  this  table  the  enormous  frequency  of  tuberculosis,  even  in  child- 
hood, will  be  seen.  It  must  not  be  forgotten,  however,  that  these  figures 
are  obtained  in  a  children's  clinic  frequented  by  the  poorest  of  the  popula- 


TUBERCULOSIS  725 

tion  of  a  large  city.  Schlossmann  properly  calls  attention  to  the  fact  that 
conclusions  as  to  the  frequency  of  tuberculosis,  among  wage-workers  alone, 
can  be  drawn  from  these  figures  and  that  the  better  situated  classes  would 
show  very  different  results.  Among  a  large  number  of  children  of  well-to-do 
parents  he  found  only  about  5  per  cent,  of  positive  reactions. 

These  differences  between  the  poor  and  the  rich  are  due,  doubtless,  to 
the  great  fact  that  among  the  former  there  are  to  be  found  a  larger  number 
of  adults  with  open  phthisis  and  that  these  affected  persons  live  in  closer 
contact  with  the  children.  If  there  is  an  open  case  to  spread  tubercle  bacilli 
in  a  family  all  the  children  become  infected.  Pollok  found  that  of  285 
children  who  lived  in  a  tuberculous  environment,  only  six  gave  negative 
and  279  gave  positive  tuberculin  reactions.  He  then  undertook  to  deter- 
mine whether  the  time  of  infection  had  any  effect  upon  the  form  of  the 
disease.  He  learned  when  the  phthisis  began  in  each  open  case  and  from 
this  he  calculated  the  age  at  which  the  children  were  liable  to  infection. 
From  this  inquiry  he  discovered  the  important  fact  that  of  fifty-seven 
children  who  had  not  come  in  contact  with  an  open  case  until  after  their 
third  year,  only  seven  exhibited  clinical  manifestations  of  the  disease,  while 
the  rest  showed  their  infection  merely  by  the  positive  tuberculin  reaction; 
that  is,  they  had  escaped  with  a  primary  lesion  and  the  involvement  of  the 
regional  lymph  glands.  Of  sixty-one  children  infected  during  the  second 
and  third  years,  forty-five  showed  clinical  symptoms  which  resulted  in  the 
death  of  seventeen  of  them.  No  spread  of  the  process  occurred  save  in 
eighteen  cases. 

The  findings  for  the  first  year  were  the  most  important.  Of  207  who 
were  exposed  to  infection  at  this  age,  only  7  or  3  per  cent.,  remained  without 
symptoms.  All  the  rest  became  ill  and  ninety-one  of  the  cases  proved  fatal. 

CLINICAL  MANIFESTATIONS 
PRIMARY  STAGE 

Even  though  tuberculous  infection  may  occur  at  any  age,  as  indicated  by 
the  appearance  of  a  primary  focus,  the  clinical  symptoms  of  this  stage  are 
recognized  only  in  infancy.  In  older  children  their  onset  has,  so  far,  es- 
caped recognition. 

The  general  manifestations  of  this  primary  stage  are  fever,  emaciation, 
and  anemia.  The  fever  may  appear  either  in  characteristic  evening  rises,  or 
it  may  be  very  irregular  in  its  onset.  Sometimes  only  very  slight  rises  above 
the  normal  point  are  seen.  The  emaciation  may  begin  very  suddenly, 
especially  in  young  infants.  In  older  children,  and  more  rarely  in  infants,  it 
may  be  absent  for  a  long  time.  In  severe  emaciation  the  skin  has  a  wilted 
appearance,  a  very  constant  manifestation  of  cachexia  in  childhood.  Night- 
sweats  are  common  among  case*  in  childhood,  but  are  rare  in  infancy. 
Anemia,  like  the  cachexia,  may  be  extreme  in  some  cases  and  entirely  lack- 
ing in  others.  All  in  all,  these  general  initial  symptoms  are  veryindefiniteand 
may  serve  only  to  excite  a  suspicion  of  tuberculosis,  which  may  be  confirmed 
by  a  tuberculin  reaction  or  by  the  appearance  of  local  manifestations  of 
the  disease. 


726 


TEXT-BOOK  OF  PEDIATRICS 


The  local  developments  of  the  primary  stage  depend  entirely  upon  the 
localization  of  the  primary  lesion.  In  by  far  the  larger  number  of  cases  this 
is  in  the  lung  and  the  symptoms  then  are  due,  in  part,  to  the  focus  in  the 
lung  tissue,  but  more  especially  to  the  swelling  of  the  bronchial  and  tracheal 
lymph  nodes  in  its  immediate  region 

TUBERCULOSIS  OF  THE  BRONCHIAL  LYMPH  NODES 

Cough  is  usually  the  first  symptom  that  calls  attention  to  the  condition. 
It  is  of  a  hollow,  barking  quality,  with  a  metallic  ring,  and  occurs  period- 
ically. It  may  become  so  severely  paroxysmal  as  to  remind  one  of  early 
pertussis,  from  which  it  can  be  distinguished  only  by  its  course.  True 
whooping-cough  goes  on  to  severe  inspiratory  attacks  with  cyanosis  and 

vomiting  in  the  course  of  a  few 
weeks;  but  a  tuberculous  cough  re- 
mains the  same  or  is  accompanied 
by  signs  of  expiratory  dyspnosa. 
This  dyspnoea  is  caused  by  the  pres- 
sure of  the  swollen  peritracheal 
nodes  upon  the  trachea  and  bronchi 
and  is  the  more  frequent  the  younger 
the  child,  because  the  thinner  and 
the  softer,  the  respiratory  tubes  the 
more  readily  are  they  compressed. 

At  autopsy,  the  larger  right 
bronchus  is  usually  found  to  be 
compressed  by  large  and  caseated 
lymph  nodes.  This  generally  occurs 
at  a  point  between  the  bifurcation 
and  the  separation  of  the  bronchus 

FIG.  180. — Tuberculous    bronchial   lymph  nodes,         f         j.i^       IITM-.OT.   1/^Ka    /"Qr>V>i*«M         T'Vin 
right  side.     (Children's  Hospital,  Vienna.)  lor   tne    Upper   1OD6    (feCniCKj.        1  He 

expiratory  dyspnoea  is  characterized 

by  a  loud  whooping  which  lengthens  the  expiration  and  makes  it  seem 
forced.  The  inspiration  is  hardly  audible  and  is  often  accompanied  by  a 
retraction  of  the  thorax  in  this  phase.  The  frequency  of  the  respiratory 
rhythm  is  not  notably  increased.  If  the  child  has  cried  or  coughed  severely, 
the  breathing  may  be  very  labored  for  a  time,  but  with  rest  the  expira- 
tion gradually  becomes  quieter  and  in  mild  cases  the  sound  may  disappear 
entirely  (Schick). 

As  a  result  of  marked  pressure  upon  the  trachea,  the  persistently  dif- 
ficult expiration  may  lead  on  to  atelectasis  of  the  lung,  while  the  compres- 
sion of  the  blood-vessels  is  shown  by  the  distended  veins  and  the  cyanosis 
of  the  head,  the  face,  the  thorax  and  the  drumstick  fingers 

The  enlarged  nodes  cannot  always  be  demonstrated  physically.  It  is 
often  possible  with  the  Roentgen  picture,  but  seldom  by  percussion. 

D'Espine's  sign  may  be  of  some  aid  in  demonstrating  the  enlarged 
nodes.  This  sign  depends  upon  the  change  of  the  voice  sounds  at  the 
bifurcation  of  the  trachea  as  heard  over  the  spine.  The  change  normally 


TUBERCULOSIS  727 

occurs  at  the  level  of  the  seventh  cervical  spine  or  possibly  at  the  level  of 
the  first  dorsal.  When  the  change  is  much  lower  it  may  be  due  to  the  trans- 
mission of  the  sound  by  the  enlarged  nodes  in  this  region. 

The  Roentgenogram  shows  spots  beside  the  spinal  column.  These  are 
seen  chiefly  on  the  right;  on  the  left  they  are  often  covered  by  the  heart. 
We  must  remember  that  at  this  point  the  blood-vessels  of  the  hilus  always 
cause  a  shadow  and  the  diagnosis  of  tuberculosis  may  be  made  when  the 
shadow  is  larger  and  more  intense  than  usual. 

In  those  cases  in  which  disease  of  the  bronchial  nodes  has  advanced  far 
enough  to  give  the  symptom  of  expiratory  dyspnoea,  the  Roentgen  picture 
is  usually  very  convincing  (Figs.  180-181) .  The  percussion  over  the  spinous 
processes  gives  slight  dulness  in  the  region  of  the  upper  thoracic  vertebrae 
(de  la  Camp),  which  cannot,  however,  be  demonstrated  beyond  controversy. 
A  dulness  in  the  intrascapular  space,  especially  toward  the  right,  is  more 


FIG.  1.81.—  Tuberculosis  of  the  bronchial  lymph  nodes 
and  of  the  right  upper  portion  of  the  lun<>-  in  a  ten-month- 
old  child  (Schick-Sluka) 

significant.  Anteriorly,  dulness  to  the  right  of  the  sternum  is  not  com- 
monly due  to  disease  of  the  bronchial  nodes  alone,  but  is  also  caused  by 
tuberculous  peribronchitis. 

PRIMARY  TUBERCULOSIS  OF  THE  LUNGS 

This  suggests  a  further  local  symptom  of  primary  tuberculosis,  incident 
to  the  unavoidable  spread  of  the  bacilliary  focus  in  the  lung  to  the  surround- 
ing tissue. 

In  older  children  the  primary  stage  usually  ends  with  the  infection  of  the 
lymph  nodes;  but  in  the  infant  the  infection  passes  directly  to  the  neighbor- 
ing tissue.  From  the  primary  focus  in  the  lung  or  by  the  rupture  of  a  ca- 
seated  regional  node  into  a  bronchus,  the  infection  spreads  to  the  adjoining 
lobe,  resulting  in  either  a  tuberculous  bronchitis  or  a  caseating  pneumonia. 

The  symptoms  of  this  bronchitis  can  be  distinguished  from  those  of 
catarrhal  bronchitis  by  the  general  manifestations  which  it  accompanies  and 
by  the  chronic  course  it  pursues.  It  is  characterized  by  a  dry  cough  without 


728  TEXT-BOOK  OF  PEDIATRICS 

expectoration,  hectic  fever  and  a  bad  general  condition.  The  history  of 
tuberculous  pneumonia  is  somewhat  more  distinctive.  It  is  differentiated 
from  lobar  pneumonia  by  the  absence  of  a  high  continuous  fever  and  the 
ensuing  crisis,  and  from  broncho-pneumonia  by  its  slight  subjective  mani- 
festations and  its  long  duration.  It  is  distinguished  from  the  chronic 
broncho-pneumonia,  often  seen  in  measles,  pertussis  and  diphtheria,  by  the 
tuberculin  reaction  alone.  The  pleura  shares  in  the  process  at  the  point 
where  the  tuberculous  focus  reaches  it.  An  adhesive  pleuritis  occurs  which 
is  hardly  ever  diagnosed  during  life. 

Pollak's  compilation  may  be  employed  to  give  some  idea  of  the  fre- 
quency of  the  individual  symptoms  in  infancy.  Among  ninety-two  tu- 
berculous infants,  forty-six,  or  one-half,  had  clinical  symptoms  due  to 
involvement  of  the  bronchial  nodes,  in  the  way  of  severe  cough  or  the  ex- 
piratory whoop,  or  both.  In  seventeen  cases,  evidences  of  pulmonary  infil-. 
tration  or  cavity  formation  were  shown;  and  in  two  instances  a  serous 
pleural  exudate  was  found. 

In  twenty-two  cases,  skin  tuberculides  were  discovered;  in  six,  phlyc- 
tenula)  were  noted;  in  six  others,  tuberculosis  of  bone  (fungus,  spina  ventosa, 
etc.) ;  in  three  individuals,  other  forms  of  secondary  infection  were  observed ; 
and  seventeen  children  died  of  miliary  or  meningeal  tuberculosis. 

We  should  pay  more  attention  to  the  skin  manifestation  of  tuberculosis. 
In  doubtful  cases,  careful  inspection  of  the  entire  body  for  evidences  of  tuber- 
culides, lichen  or  erythema  nodosum  may  be  of  considerable  assistance  on 
arriving  at  a  diagnosis. 

THE  SECONDARY  STAGES;   OR  THE   GENERAL   SPREAD  OF 

TUBERCULOSIS 

The  secondary  stage  of  tuberculosis  is  characterized  by  the  spread  of 
the  tubercle  bacilli  in  various  ways.  This  spread  is  not  of  constant  occur- 
rence in  the  picture  of  the  disease.  In  all  probability,  it  is  never  seen  in 
later  childhood  after  the  ordinary  infections  of  that  period  have  developed. 
On  the  other  hand,  it  is  almost  always  the  cause  of  death  in  those  children 
who  have  been  subject  to  infection  with  the  tubercle  bacillus  during  infancy 
and  have  not  succumbed  to  its  primary  manifestations. 

The  most  serious  development  of  the  secondary  stage  is  its  miliary 
spread;  the  distribution  of  a  large  number  of  tubercle  bacilli  by  way  of  the 
blood  to  the  various  organs.  Usually,  and  particularly  in  children  of  from 
two  to  six  years,  the  meninges  are  especially  affected  and  death  follows  the 
picture  of  tuberculous  meningitis,  a  form  of  the  disease  discussed  in  an  other 
part  of  this  book  (page  458). 

If  the  bacilli  do  not  pass  to  the  brain  or  but  in  very  small  number,  the 
picture  presented  is  that  of  true  miliary  tuberculosis.  In  infants  it  is  often 
impossible  to  distinguish  its  distinct  onset,  and  the  miliary  tuberculosis  is 
recognized  only  at  autopsy. 

In  older  children,  however,  it  develops,  as  a  rule,  as  an  acute  infec- 
tious disease. 

It  may  be  supposed  that  an  incubation  period  occurs.     The  interval 


TUBERCULOSIS  729 

between  the  first  spread  of  the  infection  from  its  primary  focus  to  the 
appearance  of  its  early  general  manifestations  is  probably  one  to  two  weeks. 
This  period  may  be  entirely  without  symptoms,  or  only  such  indistinct  pro- 
dromes as  anorexia,  lassitude,  etc.,  may  be  noted.  Later,  high  fever  of  an 
irregular  type  appears,  with  rapid  pulse  and  slight  cough.  The  spleen  is  at 
the  very  least  enlarged  enough  to  be  palpable. 

The  miliary  symptoms  usually  last  two  to  fourteen  days  and  rarely 
several  weeks.  The  bronchitis  increases  and  may  become  so  severe  as  to 
simulate  tracheal  stenosis.  Slight  cyanosis  is  nearly  always  present.  The 
sensoriurn  is  usually  slightly  clouded  and  individual  signs  of  meningitic  in- 
volvement may  be  observed. 

The  differential  diagnosis  must  first  of  all  exclude  typhoid  fever;  a 
positive  Widal  reaction  indicating  typhoid  and  a  positive  tuberculin  re- 
action, tuberculosis.  Just  as  the  Widal  reaction  may  be  negative  at  the 
onset  of  typhoid,  so  the  tuberculin  reaction  may  often  be  absent  during  the 
period  of  miliary  dissemination.  A  negative  result  is  not,  therefore,  signif- 
icant. The  gradual  disappearance  of  the  reaction  when  repeatedly  applied 
or  the  occurrence  of  a  cachectic  reaction  is  of  value.  The  appearance  of 
tubercles  in  the  choroid  is  indicative  of  miliary  tuberculosis  and  for  this 
reason  an  examination  of  the  optic  fundus  should  always  be  made  even 
though  it  gives  positive  results  but  rarely.  At  times  the  Roentgenogram 
alone,  showing  the  minute  mottling  of  the  lung,  will  clear  up  a  diagnosis. 

The  X-ray  should  be  employed  on  every  case  where  there  is  a  suspicion 
of  acute  miliary  tuberculosis.  The  symptoms  and  signs  are  often  so  indef- 
inite and  the  Roentgen  findings  so  characteristic,  that  a  diagnosis  is  only 
possible  with  the  aid  of  the  X-ray  plate. 

Miliary  tuberculosis  which  can  be  recognized  clinically,  is  practically 
always  fatal.  This  is  also  true  of  the  dissemination  of  tubercle  in  the 
meninges,  so  soon  as  its  symptoms  appear.  It  is  impossible  to  affect  the 
course  of  miliary  tuberculosis  by  treatment.  The  twenty-four  cases  of 
recovery  from  meningitis  collected  by  Barber  and  Gougelet,  show  that 
children  may  survive  miliary  dissemination.  It  is  known  that  a  limited 
miliary  spread  may  often  occur  in  the  course  of  recent  tuberculosis,  without 
fatal  result,  provided  few  secondary  foci  are  formed,  and  in  not  necessarily 
vital  organs. 

Most  of  the  subcutaneous  tuberculous  deposits  of  the  secondary  stage  of 
the  disease,  can  be  explained  only  upon  the  assumption,  that  tubercle 
bacilli  get  into  the  blood-stream  and  are  arrested  at  some  point  in  the 
systemic  circulation,  where  they  form  new  colonies  which  excite  local 
reaction  processes.  The  numerous  manifestations  of  the  dieease  in  the 
skin,  the  mucous  membranes,  the  serous  membranes,  the  bones,  the  brain 
and  the  sexual  organs  belong  in  this  group  According  to  Ghon,  the  lymph 
mechanism,  which  is  almost  always  coincidently  affected,  is  not  infected 
by  way  of  the  blood  but  through  the  lymph  channels  from  peripheral  foci. 

There  is  still  another  way  by  which  tuberculosis  may  spread  Tubercle 
bacilli  from  pulmonary  foci,  reach  the  mouth  through  the  upper  air  pas- 


730  TEXT-BOOK  OF  PEDIATRICS 

sages,  being  swallowed  enter  the  digestive  tract  where  they  infect  the  intes- 
tinal mucosa  and  the  lymph  nodes  of  the  sublingual,  tonsillar,  pharyngeal, 
cervical  and  mesenteric  chains. 

SCROFULA 

In  many  children  the  secondary  stage  of  tuberculosis  leads  to  a  symp- 
tom-complex designated  as  scrofula.  While  Laennec  interpreted  this  group 
of  symptoms  as  tuberculous,  Virchow  held  that  tuberculosis  and  scrofula 
were  different  diseases  and  it  was  not  until  the  tubercle  bacillus  was  dis- 
covered that  scrofula  was  again  regarded  as  a  manifestation  of  tuberculosis. 

Why  tuberculous  infection  does  not  develop  these  phenomena  in  all 
individuals  is  still  a  matter  of  debate.  Just  at  present,  the  theory  that  an 
hereditary  predisposition,  an  anomaly  of  the  tissues,  or  a  fault  of  metabo- 
lism, determines  this  form  of  reaction  to  the  tubercle  toxin  (Escherich, 


FIG.  182. — Physiognomy  in  scrofula.  Nose  and  upper  lip  thickened,  rhi- 
nitis, conjunctivitis  (phlyctenulse  and  photophobia.  (University  Children's 
Hospital,  Munich,  Prof.  Pfaundler.} 


Moro),  is  predominant.  It  is  supposed  that  children,  suffering  with  lym- 
phatism  or  an  exudative  diathesis,  when  infected  with  tubercle  bacilli  show, 
as  a  result  of  the  peculiar  quality  of  their  tissues,  the  severe  chronic  catarrh 
of  the  mucous  membranes  and  the  bone  lesions  which  we  class  as  scrofula. 
Without  such  infection,  they  suffer  only  the  milder  indications  of  eczema 
and  bronchitis  and  a  tendency  to  enlargement  of  the  lymph  nodes. 

It  may  be  considered  improbable  that  such  an  anomaly  of  metabolism 
favors  infection  with  the  tubercle  bacilli;  nor  does  it  seem  clear  that  a  pre- 
disposition to  the  scrofulous  type  of  development  must  always  be  inherited. 
It  is  a  question  whether  the  tendency  may  not  be  acquired  with  the  tubercu- 
lous infection  at  a  certain  early  age,  or  in  the  course  of  previous  infections 
with  other  micro-organisms  as  a  result  of  frequently  repeated  small  infections. 

The  most  important  forms  of  scrofulous  disease  are  found  in  the  fol- 
lowing organs: 

1.  The  Lymphatic  System. — The  lymph  nodes  at  the  angle  of  the  jaw 
are  most  frequently  affected  to  a  noticeable  degree.  A  hard,  painless  swell- 
ing, varying  in  size  from  that  of  a  bean  to  that  of  a  cherry,  is  formed.  Pres- 


TUBERCULOSIS 


731 


ently  the  swelling  affects  other  neighboring  nodes,  especially  those  be- 
hind the  sternomastoid,  above  the  clavicle  and  in  the  sublingual  space.  A 
widespread  swelling  of  the  entire  lymphatic  system  in  the  neck  may  result. 
The  condition  must  be  differentiated  from  leucemia  by  the  blood  find- 
ings. Pseudoleucemia  is  indicated  by  a  large  spleen  and  a  negative  tuber- 
culin reaction. 

If  the  nodes  soften  and  suppurate  the  diagnosis  of  tuberculosis  becomes 
<3lear.  The  skin  over  the  enlarged  nodes  becomes  brown  and  spontaneous 
rupture  may  occur.  Fistula?  may  form  which  heal  slowly,  leaving  irregu- 
lar scars. 

Superficial  nodes  in  other  parts  of  the  body  may  be  similarly  affected. 

This,    however,    usually   occurs    only 

when  tuberculous  disease  of  the  skin, 
bone,  or  joints  has  developed  in  the 
areas  drained  by  these  nodes.  We  have 
already  discussed  the  mediastinal  and 
peribronchial  nodes  which  in  the  scrof- 
ulous form  of  tuberculosis  are  always 
considerably  enlarged. 

2.  The  Osseous  System. — Tubercu- 
lous foci  may  form  in  various  bones. 
Those  deposits  which  do  not  affect  the 
general  well-being  to  any  marked  de- 
gree, as  small  foci  in  the  bones  of  the 
fingers,  the  wrist   and  the  ankle  are 
usually  classed  as  of  the  scrofulous  type. 
Tuberculous  inflammation  in  bone  re- 
sults both  in  destruction  and  necrosis 
and  in  the  formation  of  sequestra  and 
in  periosteal  proliferation.    A  spindle- 
shaped  swelling  of    the   phalanges  is 
characteristic    (Fig.    184).     Such  foci 
may  be  absorbed,  but  more  frequently 

they  rupture,  forming  fistulae,  large  ulcers  and  ultimately  scar  tissue  which 
is  adherent  to  the  bone.  The  termination  of  the  local  infection  is  usually 
good  if  the  general  condition  of  the  child  improves. 

3.  The  Mucous  Membranes. — Hypertrophy  of  the  tonsil  and  chronic 
catarrh  of  the  respiratory  tract  of  children  of  a  lymphatic  habitus  or  with 
exudative  diathesis  cannot  be  classed  as  certainly  scrofulous,  since  they  may 
occur  without  tuberculous  infection.    The  mucous  membranes  of  the  nose, 
ears  and,  particularly,  of  the  eyes  are  involved  in  the  tuberculous  process 
in  almost  a  pathognomonic  relation. 

Lymphatic  or  phlyctenular  conjunctivitis  begins  in  small  nodules  which 
are  rapidly  surrounded  by  a  bundle-like  arrangement  of  blood-vessels. 
These  are  to  be  considered  as  arising  from  tubercle  bacilli  or  their  toxic 
derivatives  which  enter  the  conjunctival  sac  by  way  of  the  lachyrmal  duct. 

These  nodules  usually  lie  at  the  sclerotic  margin  of  the  cornea  or,  more 


FIG.  183. — Scrofula  in  a  year  and  a  half- 
old  girl.  Characteristic  face:  eczema,  espe- 
cially around  the  mouth,  nose,  and  ears. 
Thickening  of  the  upper  lip.  Photophobia 
(phlyctenular  conjunctivitis).  (Children's 
Hospital — Heidelberg,  Prof.  Peer.) 


732 


TEXT-BOOK  OF  PEDIATRICS 


rarely,  in  the  middle  field  of  the  cornea.  Their  surface  soon  becomes  eroded 
and  a  small  ulcer  forms  which  commonly  heals  within  two  or  three  weeks. 
This  feature  of  the  disease  is  in  itself  benign,  but  mechanically  it  often  in- 
volves great  danger  to  the  eye  when  the  lesion  is  in  the  cornea  and  the 
ulcers  affect  the  deeper  layers.  When  this  happens  the  remaining  thin 
layers  may  bulge  and  rupture  in  consequence  of  the  intra-ocular  pressure. 
If  the  content  of  the  anterior  chamber  is  evacuated  the  iris  is  dragged  into 


Flo.  184. — Multiple  spina  ventosa. 

the  wound,  which  may  lead  to  permanent  deformity  and  to  secondary 
disease  of  the  eye. 

Even  though  the  disease  of  the  cornea  is  less  deep,  it  usually  leaves  on 
healing  some  cloudiness  which  persists  throughout  life.  Only  very  super- 
ficial phlyctenulae  heal  without  scars.  The  individual  attack  is  of  brief 
duration  but  the  tendency  to  recurrence  is  great.  Repeatedly  small  ulcers 
appear,  or  a  single  ulcer  grows  to  a  more  and  more  central  position  and  is 
marked  by  increased  vascularity.  Finally  a  more  diffuse  form  of  disease, 
the  scrofulous  pannus  of  the  cornea,  may  appear,  affecting  chiefly  the  lower 
half  of  the  cornea  and  persisting  for  a  long  time. 

The  corneal  affection  is  always  accompanied  by  a  greatly  increased 
secretion  of  tears  and  by  a  catarrhal  inflammation  of  the  connective  tissue. 
This  involves  hyperplasia  and  in  the  course  of  time,  if  the  condition  persists, 


TUBERCULOSIS  733 

leads  to  a  thickening  of  the  lids,  eczema  about  the  inner  canthus,  ectropion 
and  irregular  growth  of  the  ciliary  muscle. 

Intense  photophobia  is  very  characteristic  of  scrofulous  inflammation 
of  the  eyes  and  may  at  times  enable  one  to  make  the  diagnosis  at  a  distance. 
The  affected  child  closes  his  eyes,  hides  his  head  from  the  light  and  objects 
strenuously  to  examination  (Fig.  185). 

The  disease  as  it  appears  in  the  nose,  with  the  chronic  coryza,  the 
swelling  of  the  nostrils,  and  the  eczema  of  the  surrounding  skin  gives  a 


FIG.  185. — Scrofula.    Chronic  conjunctivitis  and  rhinitis,  with  thick  upper 
lip.     (Gisela  Children's  Hospital,  Munich,  Prof.  Ibrahim.) 

characteristic  picture  (Fig.  183).  This  has  been  described  under  Diseases 
of  the  Respiratory  Tract ;  so,  also,  has  the  chronic  catarrhal  inflammation  of 
the  middle  ear,  which  may  lead  on  to  destruction  of  the  internal  ear  if  it  is 
combined  with  caries  of  the  petrous  portion  of  the  temporal  bone. 

The  upper  lip  usually  shares  in  the  swelling,  affecting  the  nose.  The 
mucous  membrane  of  the  lips  become  fissured  and  is  covered  with  scabs. 
In  other  parts  of  the  face,  lichen,  or  a  measles-like  eruption,  or  pustules 
appear,  which  rarely  extend  to  the  skin  of  other  portions  of  the  body. 
These  eruptions  may,  indeed,  take  various  forms  and  it  is  hard  to  say  how 


734 


TEXT-BOOK  OF  PEDIATRICS 


far  they  may  be  regarded  as  of  tuberculous  origin.  Such  causal  relation 
certainly  obtains  for  the  verrucous  and  papulosquamous  tuberculides  de- 
scribed in  the  chapter  on  Diseases  of  the  Skin. 

The  manifestations  of  scrofula,  though  terrifying  in  appearance,  are 
hardly  ever  dangerous.  The  tuberculous  changes  which  terminate  fatally 
are  not  those  of  the  skin  or  of  the  mucous  membranes  or  of  the  bones  of  the 

hands  and  feet.  Of  course,  the  rupture  of 
any  focus  into  the  blood-stream  from  any 
of  these  sources  may  result,  as  it  does  in 
simple  tuberculosis  of  the  bronchial  lymph 
nodes,  and  may  terminate  in  miliary  tuber- 
culosis or  meningitis.  The  probability  of 
this  event  is  hardly  greater,  however,  than 
in  patients  in  whom  tuberculous  formations 
do  not  appear  on  the  surface. 

With  the  end  of  childhood  the  symptoms 
of  true  scrofula  usually  disappear.  They 
have  one  great  disadvantage,  as  compared 
with  the  internal  tuberculous  processes,  in 
that  they  very  often  leave  such  serious  visi- 
ble deformities,  as  the  scars  of  healed  lymph 
nodes  or  bone  disease,  or  the  cloudiness  of 
the  cornea. 

Physicians  formerly  distinguished  be- 
tween a  cachectic  and  an  erethismic  habitus 
in  scrofula.  The  former  included  what 
today  we  term  scrofula;  the  latter  is  covered 
under  the  prevailing  term  "habitus  phthis- 
icus"  (Fig.  186).  In  childhood,  the  latter 
consists  essentially  of  emaciation,  since  the 
narrow  chestedness,  so  typical  after  puberty, 
is  hardly  distinct  in  earlier  life;  of  a  poorly 
nourished,  dry,  scaly  skin,  with  excessive 
growth  of  hair.  The  face  is  of  comparatively 
healthy  appearance  and  though  the  cheeks 
are  sometimes  flushed  or  hectic,  they  are 
not  markedly  sunken.  The  cachectic  habi- 
tus is  very  often  seen  in  cases  of  visceral 
tuberculosis  and  especially,  in  tuberculosis 
of  the  serous  membranes  and  of  the  lungs. 

The  Serous  Membranes. — Nearly  all  of  the  surfaces  may  be  affected  by 
the  tubercle  bacillus,  producing  an  inflammation  which  results  in  the  for- 
mation of  a  thin  serous,  or  fibrino-caseous  exudate.  Tuberculous  affections 
of  the  pleura,  the  peritoneum,  the  pericardium,  and  the  joint  cavities  and 
synovial  sheaths  belong  in  this  class.  The  most  important  of  these  are 
tuberculous  peritonitis  (page  343),  and  adhesive  pericarditis  (page  407). 
Tuberculous  infection  of  the  bones  often  produces  serious  disease-pic- 


Fia.  186. — Habitus  phthisicus  ten- 
year-old  girl.  (University  Children's 
Hospital,  Zurich,  Prof.  Peer.) 


TUBERCULOSIS  735 

tures.  This  is  especially  true  of  disease  of  the  vertebral  column  and  of  the 
larger  joints.  Infection  in  these  parts  or  foci  in  the  ribs  may  cause  cold  ab- 
scesses which  descend  into  the  pelvis. 

Foci  may  be  found  in  any  other  bones,  in  the  testes  and  epididymis,  and 
in  the  female  generative  organs.  Finally,  tubercles  may  also  form  in  the 
brain  and  particularly  in  the  cerebellum.  They  constitute  the  most  fre- 
quent of  the  brain  tumors  of  childhood  (page  497) . 

CHRONIC  PULMONARY  TUBERCULOSIS; 
THE  TERTIARY  STAGE 

As  an  uncomplicated  disease,  tuberculosis  of  the  lungs  becomes  more  and 
more  frequent  as  we  approach  the  end  of  childhood.  This  is  especially 
true  of  the  affection  of  the  apices  so  typical  in  adults. 

From  autopsy  findings  and  animal  experiments  we  may  conclude  that 
chronic  pulmonary  tuberculosis  arises  from  the  primary  focus  as  a  tertiary 
stage.  Clinically  its  relationship  to  the  primary  and  secondary  stages  can 
be  shown  in  very  few  cases.  But  the  hereditary  taint  v/hich,  according  to 
our  present  day  knowledge,  means  nothing  more  than  an  early  infection 
from  a  phthisical  parent,  is  very  frequently  recognized. 

The  occasion  for  the  onset  of  pulmonary  disease  may  sometimes  be 
found  in  the  occurrence  of  an  infectious  disease  and,  in  particular,  of  mea- 
sles, pertussis,  broncho-pneumonia.  In  many  cases  no  recognizable  cause 
is  determinable. 

The  first  symptoms  of  pulmonary  tuberculosis  are  very  indefinite.  An 
arrest  of  gain,  or  a  slight  loss  in  weight,  lassitude,  pallor  in  the  morning  and  a 
hectic  flush  at  night  are  generally  noted.  Careful  observation  will  show 
variations  of  temperature  with  an  evening  rise.  Cough  is  not  constant  and 
expectoration  occurs  only  after  bronchial  symptoms  of  some  duration. 
Hemoptysis,  often  the  first  sign  of  phthisis  in  the  adult,  is  very  uncommon  in 
children.  If  bloody  sputum  is  found  we  must  assure  ourselves  that  it  does 
not  come  from  the  nose,  gums  or  throat.  After  several  months,  or  even  after 
two  or  three  winters,  marked  by  suggestive  symptoms,  but  followed  by  re- 
mission, the  fever  becomes  more  intense,  the  cough  more  severe  and  espe- 
cially annoying  in  the  mornings.  Often  after  such  a  period  only  do  the 
physical  signs  become  clear. 

Tympany  or  diminished  resonance  is  found  over  the  apices,  with  sighing 
or  bronchial  breathing,  usually  accompanied  by  rales.  Often  the  lower 
lobes  are  also  affected  where  cavities  are  more  easily  demonstrated,  espe- 
cially after  a  fit  of  coughing. 

At  this  stage  the  sputum  is  no  longer  swallowed  and  may  be  examined 
for  bacilli.  As  a  matter  of  self-infection  from  the  sputum,  intestinal  tuber- 
culosis, manifested  by  severe  diarrhoea,  or  tuberculous  laryngitis,  suggested 
by  hoarseness,  may  result.  As  in  the  adult,  death  ensues,  after  a  high  degree 
of  emaciation,  either  from  the  tuberculosis  itself  or  from  its  complications. 

The  tendency  to  recovery,  however,  is  decidedly  greater  in  childhood 
than  in  maturity.  With  proper  treatment  even  very  advanced  cases  may 
be  cured. 


736  TEXT-BOOK  OF  PEDIATRICS 

Diagnosis. — Tuberculosis  may  be  recognized  in  either  one  of  three 
ways:  1.  By  the  clinical  demonstration  of  a  typical  form  of  the  disease. 
2.  By  the  demonstration  of  the  tubercle  bacilli.  3.  By  the  demonstration 
of  specific  antibodies  (ergines) ,  with  the  tuberculin  reaction. 

1.  The  forms  of  disease  which  definitely  indicate  tuberculous  infection 
are,  primarily,  certain  affections  of  the  bones  and  joints,  as  spondylitis,  fun- 
gus of  the  joints  and  spina  ventosa.  Lupus  and  the  various  types  of  skin 
tuberculides  are  rare  in  childhood,  but  are  also  pathognomonic. 

The  diagnosis  is  quite  firmly  established  by  the  clinical  symptoms  of 
chronic  exudative  peritonitis,  by  the  demonstration  of  cavity  formation  in 
the  upper  lobe  of  the  lungs,  or  by  the  typical  disease-picture  of  tubercu- 
lous meningitis. 

The  presence  of  serous  pleuritis  or  the  development  of  an  expiratory 
whoop  in  the  infant  is  less  significant.  In  all  these  cases,  a  final  diagnosis 
can  be  made  only  by  the  one  or  the  other  of  these  proofs,  corroborative  of 
the  clinical  examination. 

Of  the  tuberculous  infection  of  the  lymph  nodes  veiy  much  the  same 
thing  may  be  said.  Most  of  the  cases  of  chronic  hardening  of  the  lymph 
nodes  are  undoubtedly  due  to  tuberculosis.  We  cannot  diagnose  the  dis- 
ease, however,  merely  upon  the  fact  that  numerous  small  lymph  nodes 
are  palpable.  Such  a  polyadenitis  may  be  of  non-tuberculous  origin.  To 
suggest  a  diagnosis  of  tuberculosis  the  gland  must  be  of  at  least  the  size  of 
a  cherry  and  the  swelling  must  have  persisted  for  some  length  of  time. 
Particularly  in  the  case  of  the  cervical  glands  one  should  never  be  prema- 
ture in  diagnosis,  since  other  infections  arising  in  the  mouth  may  cause 
subacute  swelling  in  this  chain.  Lymph  nodes  which  are  adherent  to  the 
skin,  and  especially  those  in  which  an  irregularly  contracted  scar  indicates 
early  rupture,  are  usually  tuberculous.  Equally  suggestive  is  the  adhesion 
of  scar  tissue  between  skin  and  bone. 

Pulmonary  manifestations  in  the  child  require  special  consideration 
before  a  diagnosis  is  matured.  Apical  catarrhs  are  not  so  characteristic  as 
in'the  adult  and  simple  dulness  or  bronchial  rales  over  the  lower  lobes  may 
be  due  at  any  time  to  a  chronic  pneumonia  of  other  origin. 

A  high  degree  of  cachexia  in  a  child,  of  from  three  to  fourteen  years, 
always  suggests  tuberculosis  as  a  matter  of  priority,  just  as  it  suggests 
a  chronic  gastro-intestinal  affection  during  infancy.  Nevertheless,  we 
should  hesitate  to  make  a  diagnosis  from  this  fact  alone  or  from  a  dry, 
hairy  condition  of  the  skin.  The  hairiness  may  be  hereditary  or  it  may  be 
the  result  of  the  cachexia  itself,  rather  than  a  specific  consequence 
of  tuberculosis. 

Roentgenography  renders  excellent  service  in  the  examination  of  the 
lungs.  The  younger  the  child,  the  more  pronounced  are  the  findings.  Ex- 
tensive tuberculous  infiltration  appears  in  the  form  of  dark  shadows  in 
which  cavities  may  often  be  recognized  as  lighter  areas.  Small  areas  of 
infiltration,  however,  especially  at  the  apices,  are  not  always  clear.  In  such 
a  case  more  definite  information  may  be  gained  by  percussion  and  ausculta- 
tion. Small  caseated  or  primary  calcified  foci  often  stand  out  very  distinctly. 


TUBERCULOSIS  737 

The  X-ray  of  the  lung  in  miliary  tuberculosis  presents  a  fine  mottled 
appearance,  which  is  more  distinct  as  the  individual  tubercles  become  older. 
Pleurisy  produces  deep  shadows,  and  a  fibrinous  pleuritic  exudate  may  be 
very  distinct  long  after  the  process  has  healed  and  is  especially  noticeable 
between  the  lobes  of  the  lung. 

The  question  of  the  recognition  of  enlarged  bronchial  nodes  is  the  sub- 
ject of  much  discussion.  Such  large  masses  of  nodes  as  are  seen  in  Fig.  180 
are  easily  discovered,  but  numerous  errors  have  been  made  in  the  diagnosis 
of  less  markedly  enlarged  glands.  The  distinction  of  the  shadows  caused  by 
these  from  the  normal  picture  of  the  pulmonary  vessels  requires  much 
practice,  which  may  be  acquired  only  with  the  control  of  tuberculin  reactions 
and  autopsy  findings.  Moreover,  it  must  not  be  forgotten  that  other  than 
tuberculous  processes,  and  particularly  in  pneumonia  and  pertussis,  may 
lead  to  the  swelling  of  the  bronchial  lymph  nodes. 

In  this  clinic  the  Roentgen  examination  of  every  child,  suspected  of 
tuberculosis,  is  insisted  upon.  In  older  children  a  fluoroscopic  examination 
is  often  sufficient,  but  in  younger  ones  it  is  better  to  take  a  picture  at  once. 
This  permits,  of  course,  only  momentary  exposures,  since  plates  given  more 
than  a  second  are  never  clear. 

2.  The  Demonstration  of  the  Tubercle  Bacillus. — While  this  demon- 
stration is  the  most  signal  requirement  of  the  diagnosis  of  tuberculosis  in  the 
adult  we  are  but  rarely  given  the  opportunity  of  its  achievement  in  children. 
This  is  due  in  part  to  the  fact  that  among  them  open  pulmonary  tuberculosis 
is  not  common,  and  further  to  the  fact  that  even  in  the  open  case  the  sputum 
is  not  expectorated,  but  is  habitually  swallowed.    In  the  chronic  phthisis  of 
older  children  an  exception  to  this  rule  is  noted. 

In  the  very  young,  the  bacilli  may  sometime  be  obtained  by  passing  an 
applicator  wound  with  cotton  into  the  pharynx,  when  the  gagging  induced 
may  bring  up  sputum.  It  may  be  secured  also  by  washing  out  the  empty 
stomach.  If  these  methods  do  not  succeed  the  bacilli  may  be  found  in 
the  stools. 

Extirpated  tonsils  may  be  examined  in  stained  section.  Suspected  ma- 
terial in  which  there  may  be  very  few  tubercle  bacilli,  such  as  exudates, 
urinary  sediments  or  spinal  fluid,  is  examined  by  the  antiformin  method, 
when,  if  the  findings  are  negative,  the  centrifugalized  material  may  be 
injected  into  a  guinea  pig. 

3.  The  Tuberculin  Reaction. — In  children  the  tuberculin  test  plays  a 
much  more  important  role  than  the  search  for  bacilli.     In  very  young 
subjects  it  should  always  be  employed  when  there  is  the  least  suspicion  of 
tuberculosis.     In  older  children  it  should  be  employed  only  when  some 
point  of  practical  consequence  depends  upon  its  positive  or  negative  out- 
come.    It  must  not  be  forgotten,  however,  that  the  tuberculin  reaction  is 
merely  a  part  of  the  examination.    Its  significance  is  valuable  only  when  due 
consideration  is  given  to  the  clinical  symptoms. 

Tuberculin  causes  a  specific  inflammation  in  the  tuberculous,  while  it  is 
entirely  without  action  in  the  non-infected.    As  already  noted,  upon  infec- 
tion with  tubercle  bacilli,  ergines,  or  substances  in  the  nature  of  antibodies 
47 


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are  formed  which,  in  the  presence  of  bacilli  or  tuberculin,  form  apotoxins, 
the  toxic  products  of  digestion.  These  antibodies  are  distributed  through- 
out the  human  organism  and  it  is  possible,  therefore,  to  produce  reactions 
in  any  part  of  the  body  by  introducing  tuberculin. 

Wherever  tuberculin  and  these  antibodies  come  together  apotoxin  is 
formed.  The  reaction  occurs  first  as  a  local  manifestation  at  the  point 
of  entry;  and  later,  as  a  focal  reaction,  at  those  points  where  tuberculous 
deposits  and  probably,  therefore,  a  large  number  of  antibodies  are  found. 
The  reaction  may  develop  in  the  original  tuberculous  focus,  or  at  any 
place  where  tubercle  bacilli  are  gathered,  or  may  even  reappear  at  some 
point  where  a  former  tuberculin  injection  had  been  given.  Further,  a 


Cutaneous  tuberculin  reaction. 


FIG.  187. — Applying  tuberculin. 


FIG.  188. — Vaccination. 


general  reaction  is  manifested  by  fever  and  malaise,  which  is  accounted  for 
either  by  the  formation  of  apotoxins  in  the  central  viscera  or  by  their 
absorption  from  tuberculous  foci. 

Focal  and  general  reactions  occur  only  when  a  large  quantity  of  tuber- 
culin gets  into  the  circulation.  In  the  application  of  tuberculin  to  the  skin 
or  the  mucous  membranes  a  general  reaction  is  exceptional,  since  so  small 
an  amount  of  tuberculin  is  absorbed.  It  may  be  avoided  in  subcutaneous 
injections  by  the  use  of  minimal  doses. 

The  recognized  methods  for  the  introduction  of  tuberculin  are  the  sub- 
cutaneous or  intracutaneous  injection,  cutaneous  vaccination,  percutaneous 
inunction,  and  conjunctival  instillation. 

As  the  first  test,  the  cutaneous  vaccination  is  preferred.  If  this  is  re- 
fused by  the  patient,  inunction  is  employed.  The  intradermal  test  serves 
as  a  further  check  in  the  case  of  negative  results,  and  the  subcutaneous 
method  serves  to  develop  focal  reactions. 


TUBERCULOSIS  739 

The  technic  of  cutaneous  vaccination  is  as  follows:  The  skin  of  the 
forearm  is  cleansed  with  ether.  A  drop  of  Koch 's  old  tuberculin  is  placed 
with  a  pipette  or  glass  rod  at  each  of  two  points  upon  the  skin,  about  10  cm. 
(4  inches),  apart.  A  vaccinating  borer,  the  platinum  tip  of  which  has  been 
sterilized  by  heating,  is  twisted  at  a  point  halfway  between  the  drops,  thus 
giving  a  control.  The  same  proceeding  is  had  upon  the  skin  through  each 
drop  of  tuberculin. 

A  positive  reaction  appears  in  a  few  hours,  at  the  earliest,  and  usually 
within  twenty-four  hours.  The  red  areas  which  appear  immediately  after 
the  vaccination  are  merely  traumatic  and  may  be  seen  equally  at  the  control 
point.  The  specific  reaction  consists  of  a  raised,  red,  indurated  papule  of 
from  5-25  mm.  in  diameter. 

If  the  papule  does  not  reach  a  diameter  of  5  mm.  it  is  not  to  be  con- 
sidered as  definitely  positive,  even  though  the  vaccination  points  appeal- 
larger  than  the  control.  Tuberculin  may  produce  such  a  slight  local  reaction 
even  in  non-tuberculous  persons;  the  test  should  be  repeated  in  such  cases. 
If  the  first  slight  reaction  is  positive,  upon  repetition  it  will  be  more  definite. 

Successive  increase  of  the  positive  reaction  is  due  to  the  fact  that  the 
inoculation  of  even  so  small  an  amount  of  tuberculin  in  the  tuberculous 
individual  has  an  influence  on  the  formation  of  antibodies  which  stimulates 
the  organism  to  the  increased  formation  of  ergines.  A  torpid  or  secondary 
reaction  depends  upon  this.  As  previously  stated,  an  early  reaction  com- 
monly appears  within  twenty-four  hours;  more  rarely  it  is  postponed  to 
forty-eight  hours.  There  are  occasional  cases  of  torpid  reaction,  in  which 
the  papule  is  seen  only  after  two,  three  or  even  eight  days.  These  instances, 
however,  are  almost  always  in  individuals  who  are  clinically  free  from  apparent 
tuberculosis,  or  in  those  who  show  healed  tuberculous  lesions.  This  applies 
also  to  the  secondary  reaction.  In  older  children  and  in  adults,  it  frequently 
happens  that  there  is  no  reaction  upon  the  first  attempt,  but  that  a  second- 
ary response  appears  upon  the  repetition  of  the  test  in  eight  days.  Such 
persons  are  not  necessarily  irresponsive  to  tuberculin  upon  the  first  occasion, 
but  they  are  less  sensitive  than  usual.  If  a  subcutaneous  or  intracutane- 
ous  injection  is  given  with  a  relatively  high  dose  of  tuberculin  they  prove 
capable  of  reaction  (F.  Hamburger) .  Yet,  they  stand  these  high  doses 
without  general  reaction,  because  their  sensitivity  is  slight. 

The  following  method  of  procedure  is  recommended  for  complete  ex- 
amination :  The  cutaneous  test,  already  described  is  carried  out  first  and 
the  points  of  inoculation  are  examined  after  twenty-four  hours.  If  the 
reaction  is  present  its  extent  is  noted  and  inspected  again  after  a  second 
twenty-four  hours. 

If  the  reaction  is  negative  and,  even  though  the  tuberculin  inoculation 
points,  corresponding  to  the  wounds  made  with  the  instrument,  are  distinct, 
we  should  wish  to  determine  definitely  that  there  is  no  power  of  reaction, 
one  milligram  (Ko  c.c.),  of  a  1  per  cent,  dilution  of  old  tuberculin  may  be 
injected  into  the  skin,  as  superficially  as  possible,  with  a  fine  needle  (Mantaux 
or  Stich  reaction).  The  dilution  is  best  prepared  in  a  Fornier  syringe,  taking 
up  0.1  c.c.  of  tuberculin  first  and  then  0.9  c.c.  of  sterile  water.  This  is  to  be 


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mixed  by  thorough  shaking,  after  which  the  excess  of  0.9  c.c.  is  thrown  away 
and  the  syringe  is  again  refilled  to  1  c.c.  with  sterile  water.  Instead,  the  dilu- 
tion may  be  made  by  placing  5  c.c.  of  sterile  water  in  a  watch-glass,  and 
adding  one  drop  (0.05  c.c.)  of  old  tuberculin  and  mixing  it  by  drawing  the 


FIG.  ISO. — Cutaneous  reaction  with  various  dilutions  of  tuberculin. 

fluid  into  the  syringe  several  times.  The  doses  need  not  be  absolutely  exact. 

A  positive  reaction  results  in  a  reddened  area  of  painful  infiltration 
which  remains  sensitive  several  days.  Intense  reactions  are  easily  inter- 
preted, but  slight  ones  are  often  doubtful.  With  the  subcutaneous  test  a 
clear  result  is  obtainable  in  most  cases,  if  not  in  all. 

If  one  does  not  wish  to  use  the  subcutaneous  injection  on  account  of  the 
ever  present  possibility  of  a  rise  in  temperature,  the  cutaneous  test  may 
be  repeated  after  a  week's  delay.  Usually  an  increased  power  of  reaction, 


TUBERCULOSIS 


741 


has  been  established  by  that  time,  if  allergy  has  ever  been  created.  If  the 
injection,  or  the  second  application  of  the  cutaneous  test,  proves  negative, 
the  existence  of  tuberculosis  may  be  excluded  quite  definitely;  taking  into 
due  consideration,  however,  the  few  cases  in  which  the  power  of  reaction 
is  diminished. 

If  the  patient  refuses  vaccination,  the  Moro  percutaneous  test  may  be 
applied.  This  test  depends  upon  the  premise  that  sufficient  tuberculin  may 
be  rubbed  into  the  skin  by  thorough  inunction  to  produce  a  reaction.  For 
this  purpose  either  undiluted  old  tuberculin  or  Moro 's  tuberculin  ointment, 
prepared  with  equal  parts  of  Koch's  tuberculin  and  lanolin  is  used.  A 
portion  of  the  ointment,  the  size  of  a  pea  is  rubbed  into  the  skin  of  the 
back  or  abdomen  over  an  area  about  five  centimeters  in  diameter. 

A  positive -react  ion  requires  the  same  time  for  its  development  as  in 
cutaneous  vaccination.  It  consists  of  small  lichen-like  nodules.  If  there  is 


Fio.  190. — Severe  cutaneous  reaction  with  formation  of  areola.    Forty-eight  hours 
after  application  of  the  test.     Two  areas  of  vaccination,  control  in  centre. 

marked  sensitivity,  the  nodules  are  very  dense  and  the  surrounding  skin  is 
reddened.  If  thoroughly  and  carefully  applied,  the  test  is  almost  as  delicate 
as  the  vaccination,  but  is  subject  to  many  sources  of  error. 

The  instillation  of  a  1  per  cent,  dilution  of  tuberculin  into  the  con- 
junctiva (Calmette),  causes  conjunctivitis  in  tuberculous  individuals.  This 
test  cannot  be  recommended  for  children,  because  it  may  be  followed  by  a 
long  continued  inflammation  of  the  eye. 

On  account  of  the  danger  of  very  serious  fever  resulting  from  the  original 
method  of  injection,  as  devised  by  Koch,  it  is  no  longer  used  in  children,  un- 
less their  sensitivity  has  been  previously  determined  by  local  tests,  and  is 
then  given  only  by  gradual  stages  with  intervals  of  days  between  doses 
(Loewenstein  and  Rappaport).  The  procedure  is  much  more  tedious  than 
the  methods  described.  A  further  difficulty  of  its  use  lies  in  the  fact  that 
this  temperature  test  can  be  employed  only  in  patients  who  are  free  from 
fever.  The  injection  is  indicated,  nevertheless,  if  one  wishes  to  obtain  a 
focal  reaction  in  such  cases  as  suspected  tuberculosis  of  the  bladder.  The 
injection  should  be  preceded  by  the  cutaneous  test.  If  this  is  negative,  one 


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milligram  of  tuberculin  may  be  injected  at  the  outset.  If  the  cutaneous 
test  is  positive,  the  injection  should  begin  with  ^Oo  mg->  and  this  should 
be  increased  to  ^lo  mg-  and  finally  to  1  mg.,  if  no  focal  or  general  reaction 
is  shown. 

What  Does  the  Positive  Tuberculin  Reaction  Signify? — It  is  still  fre- 
quently interpreted  as  signifying  tuberculous  disease.  This  is  incorrect. 
A  positive  reaction  signifies  merely  that  the  individual  has  formed  anti- 
bodies against  tuberculosis,  that  he  has  at  some  time  been  infected  by 
tubercle  bacilli.  In  fact,  the  infection  need  not  have  caused  actual  disease, 
but  may  have  been  confined  to  a  few  unimportant  lymph  nodes. 

The  formation  of  antibodies  in  the  organism  is  at  its  height  during  the 
years  immediately  following  the  infection,  or  during  a  recrudescence  of  the 
disease  process,  or  after  a  reinfection.  An  intense  tuberculin  reaction  to  a 
first  test  indicates  that  a  new  factor  has  developed  in  the  course  of  the 


FIG.  191. — Moderate  reaction.    (Figs.  172-174  from  wax  models  by  Dr.  Henning,  Vienna.) 

tuberculosis.  It  does  not  prove,  however,  that  the  disease  is  progressing; 
it  may  be  receding. 

Clinical  examination,  however,  discovers  foci  suggestive  of  tuberculo- 
sis and  if  general  symptoms,  emaciation  and  the  like,  coexist,  the  reaction 
may  be  laid  to  tuberculosis  with  reasonable  certainty.  This  probability  is 
the  greater  the  younger  the  child,  since  tuberculosis  is  rarely  latent  in 
young  children. 

The  Significance  of  a  Feeble  Reaction. — Slight,  torpid,  or  secondary 
reactions,  and  those  which  appear  only  after  the  subcutaneous  injection  of 
large  doses  of  tuberculin  have  one  and  the  same  meaning.  They  show  that 
the  organism  has  been  infected  at  one  time,  but  is  no  longer  at  the  height 
of  its  formation  of  antibodies.  This  condition  is  chiefly  characteristic  of 
healed  processes,  but  may  obtain  in  long-standing  progressive  tuberculosis. 
The  pulmonary  tuberculosis  of  adults  often  gives  these  weak  reactions. 

Furthermore,  certain  processes  may  cause  anergy,  or  reduction  or  loss 
of  sensitivity  during  an  active  tuberculosis.  Among  these  are : 


TUBERCULOSIS  743 

1.  Miliary  Tuberculosis. — The  tuberculin  reaction  fails  quite  commonly 
in  older  children  during  the  last  week  of  miliary  tuberculosis  or  tuberculous 
meningitis.  It  may  be  lost,  also  during  recurrences  of  miliary  dissemination 
which  do  not  prove  fatal. 

•  2.  Measles,  as  we  have  previously  noted,  always  reduces  to  a  minimum 
the  sensibility  to  tuberculin.  According  to  the  reports  of  several  authors 
lobar  pneumonia  has  a  similar  influence. 

3.  Previous  Treatment  with  Tuberculin. — While  the  introduction  of 
minimal  doses  of  tuberculin  results,  in  the  course  of  several  days,  in  increas- 
ing the  power  of  reaction  which,  on  the  contrary,  is  decreased  by  the  injec- 
tion of  larger  doses  ( Vallee,  F.  Hamburger) .  The  immunity  to  tuberculin 
occurring  upon  rapid  increase  of  dosage,  as  in  the  old  method  of  Koch 
(Schlossmann),  must  be  laid  to  the  absorption  of  the  antibodies  (F. 
Hamburger) ,  or  to  the  development  of  anti-anaphylaxis  (Bessau) .  Whether 
the  loss  of  sensibility  after  very  gradual  increase  of  doses,  as  in  Sahli's 
meth3d,  is  to  be  explained  in  this  way  or  to  be  regarded  as  the  development 
of  a  true  immunity  to  tuberculin  is  not  quite  clear. 

What  is  the  Significance  of  a  Negative  Reaction?. — If  all  three  of  these 
factors  in  determining  a  negative  reaction  can  be  ruled  out,  a  single  negative 
result  indicates  a  definite  poverty  of  antibodies  and  very  probably  the 
absence  of  any  active  disease  process.  In  young  children  it  may  be  accepted 
as  evidence  that  there  is  no  tuberculosis  present.  Two  negative  reactions 
are  well-nigh  conclusive. 

An  exception  is  to  be  noted  in  cases  of  very  recent  infection.  It  takes 
some  time  to  develop  the  sensibility  to  tuberculin.  Reaction  to  the  subcu- 
taneous injection  appears  earlier  than  to  cutaneous  inoculation.  A  quan- 
titative reduction  of  the  tuberculin,  illustrated  in  Figure  189,  is  largely 
of  theoretic  interest.  The  more  dilute  the  tuberculin  which  gives  an  initial 
positive  reaction,  the  greater  will  be  the  papule  which  results  at  the  point 
of  vaccination  when  undiluted  tuberculin  is  used;  so  that  the  papule  serves 
as  an  approximate  index  to  the  intensity  of  the  development  of  antibodies. 

Prognosis. — Tuberculosis  is  not  to  be  regarded  as  a  disease,  the  course  of 
which  is  determined  by  time  or  by  degree  of  infection,  as  measles  which 
runs  its  course  in  fourteen  days,  or  leprosy  which  is  slowly  but  surely  fatal. 
The  only  constant  elements  in  tuberculous  infection  are  the  formation  of 
the  primary  lesion  and  the  reaction  of  the  regional  lymph  nodes.  The 
development,  the  number  and  the  extent  of  secondary  lesions,  and  their 
implication  of  vital  organs  depend  upon  more  or  less  accidental  circumstances. 

If  the  opportunity  of  making  a  diagnosis  is  given  during  the  primary 
stage,  when  only  an  initial  lesion  of  the  skin,  perhaps,  or  an  expiratory 
dyspnoea,  or  a  positive  tuberculin  reaction,  without  accompanying  symp- 
toms, is  discoverable,  the  prognosis  is  governed  by  the  age  of  the  patient. 
During  the  first  year  all  the  probabilities  point  to  a  fatal  termination  or  at 
least  to  the  prospect  that  the  child  will  develop  distinct  clinical  symptoms. 
On  the  contrary,  in  a  child  of  eight  years  or  so,  while  the  possibility  of  the 
spread  of  the  disease  cannot  be  gainsaid,  it  is  altogether  likely  that  no 
further  symptoms  will  appear  and  that  the  secondary  or  tertiary  stage  will 


744  TEXT-BOOK  OF  PEDIATRICS 

not  ensue.  Any  child  who  has  a  recent  tuberculous  focus  may  develop  a 
disseminated  tuberculosis  at  any  time;  but  it  is  nevertheless  true  that  the 
probability  of  a  miliary  dissemination  decreases  from  year  to  year.  Herbert 
Koch  has  estimated  that  in  children  during  their  first  four  years,  the  danger 
of  tuberculous  meningitis  is  one  hundred  and  twenty  times  as  great  as  it  is  in 
between  the  tenth  and  the  fourteenth  year.  Since  the  tuberculin  reaction 
has  come  to  be  of  so  freqent  use  among  infants,  a  large  number  of  cases 
has  been  found  which  have  survived  infection  even  at  this  dangerous  age 
(Schick).  Hahn  has  followed  sixty-nine  infants  who  had  responded  posi- 
tively to  the  tuberculin  reaction  and  has  found  that  of  those  in  their  first 
year,  17  per  cent,  survived  the  disease;  in  the  second  year,  26  per  cent. ; 
while  of  those  who  gave  a  first  positive  reaction  during  the  third  year,  39 
per  cent,  escaped. 

Even  in  the  second  stage  of  tuberculosis,  the  prognosis  depends  entirely 
upon  the  extent  of  the  disease.  Thus,  a  widespread  miliary  affection  which 
develops  meningeal  symptoms  will  be  fatal.  Isolated  infections  must  be 
judged  according  to  the  vital  importance  of  the  organ  involved.  A  tubercle 
the  size  of  a  walnut,  situated  in  the  bronchial  nodes,  may  remain  undis- 
covered or  cause  only  a  slight  cough,  while  occurring  in  the  brain  it  would 
prove  fatal.  A  fungus  of  the  knee-joint  is  annoying  but  is  not  dangerous  to 
life,  whereas  the  same  lesion  in  the  vertebral  column  leads  to  compression  of 
the  cord,  paralysis,  etc.  An  adhesive  tuberculosis  of  a  synovial  sheath  is 
not  seriously  disturbing;  a  similar  adhesion  in  the  pericardium  gravely 
affects  the  heart  action.  A  miliary  tubercle  which  causes  no  symptoms  at 
all  in  the  lung,  may  lead  to  the  loss  of  an  eye  if  it  occurs  on  the  cornea. 

The  secondary  stage  in  itself  always  has  a  rather  favorable  prognosis. 
Innumerable  children,  some  of  them  marked  for  life  with  stiff  joints,  clouded 
cornea,  kyphoses,  or  at  the  least  with  scars  resulting  from  broken-down 
lymph  nodes,  still  survive. 

The  tertiary  stage  of  tuberculous  infections  and  the  pulmonary  forms  in 
general  must  be  judged,  in  the  main,  by  the  extent  of  the  process  and  the 
general  condition  of  the  patient.  Small  foci  frequently  spread  if  it  is  im- 
possible to  improve  the  nutritive  status.  The  prognosis  of  pleurisy  is  good 
if  it  is  not  accompanied  by  extensive  pulmonary  spread.  Laryngeal  and 
intestinal  tuberculosis  must  be  considered  serious  for  the  reason  that  they 
are  generally  the  result  of  severe  pulmonary  disease. 

Prophylaxis. — The  great  essential  factor  in  the  prevention  of  tuber- 
culosis is  the  separation  from  the  child  of  all  persons  who  expel  tubercle 
bacilli.  During  the  first  year,  the  infant  should  be  fairly  well  isolated;  being 
protected  from  contact  with  strange  children  and  adults  as  much  as  possible. 
Every  chance  of  tuberculous  infection,  every  casual  meeting  with  a  phthi- 
sical individual,  is  a  menace  to  the  infant.  In  certain  families  one  child 
after  another  dies  from  tuberculous  infection  which  may  be  traced  to  a 
grandparent,  to  a  neighbor,  or  to  a  servant  who  does  not  suspect  that  the 
chronic  cough  which  has  troubled  him  from  youth  is  infectious.  The  atten- 
tion of  parents  should  be  invited  to  the  fact  that  children  should  be  shielded 
from  intercourse  with  all  persons  who  suffer  with  a  cough. 


TUBERCULOSIS  745 

Prophylaxis  is  far  more  difficult  when  the  mother  herself  is  a  suspect. 
In  advanced  forms  of  tuberculosis  in  the  mother,  nursing  is  contraindicated 
for  her  own  sake,  and  the  infant  should  be  removed  from  the  house.  With  a 
slight  infection  the  mother  may  nurse  her  babe,  but  she  should  be  impressed 
with  the  fact  that  to  caress  the  child  or  to  cough  in  its  near  presence  may 
prove  fatal  to  it. 

In  well-to-do  families  the  chances  of  the  practical  observance  of  such 
precautions  are  better  than  among  the  poor  with  whom  tuberculosis  is  so 
common.  The  latter  class  of  cases  can  be  efficiently  helped  only  by  the 
exhaustive  and  systematic  attention  given  to  the  phthisical  in  sanatoria  and 
other  similar  institutions. 

Treatment. — The  primary  stage  of  tuberculosis  is  hardly  amenable  to 
treatment.  In  the  secondary  stage  there  is  greater  opportunity  to  influence 
the  general  condition  to  the  patient.  In  chronic  cases  and  especially  in  the 
tertiary  stage,  the  tendency  of  the  organism  to  recovery  may  be  markedly 
assisted  by  treatment. 

Three  methods  may  be  adopted:  1.  The  reinforcement  of  metabolism 
by  a  general  improvement  in  nutritive  conditions ;  2.  The  specific  formation 
of  bodies  protective  against  the  infection  through  the  agency  of  tuberculin. 
3.  Failing  the  complete  destruction  of  the  infective  organisms,  the  surgical 
removal  of  superficial  foci  within  reach  of  the  knife,  or  the  functional  resting 
of  the  lung  by  the  development  of  a  nitrogen  pneumothorax.  In  the  pur- 
suit of  these  methods  we  must  not  forget,  however,  that  tuberculosis  is 
a  constitutional  disease  and  that  we  have  at  present  no  therapy  of  gen- 
eral sterilization. 

With  a  view  to  the  constitutional  upbuilding  of  the  patient,  attention 
must  be  directed  to  an  improvement  of  appetite  and  an  increase  of  food- 
supply.  The  best  stimulants  to  this  end  are  light  and  air  and  a  change  of 
environment,  dwelling  and  dietary.  All  varieties  of  climatic  resort  have 
been  advised,  in  the  course  of  years,  for  the  tuberculous;  the  moist  warmth 
of  the  Riviera  and  the  dry  heat  of  the  desert ;  the  moist  cold  of  the  northern 
seacoast  and  the  dry  cold  of  the  Alps.  The  common  factors  of  them  all  are 
the  change  of  environment,  the  suggestion  of  recovery  which  directly  stim- 
ulates the  appetite,  and  the  increased  opportunity  of  life  in  the  open  air 
and  in  the  sunlight.  All  this  hardly  requires  any  particular  health  resort. 
The  same  results  can  be  obtained  under  efficient  institutional  care  within  the 
cities.  In  the  home,  however,  it  is  hardly  ever  possible  to  so  modify  the 
life  of  the  family  as  to  enable  the  patient  to  live  in  the  open  as  he  can  very 
easily  at  the  seashore.  The  worst  feature  of  treatment  is  confinement  to 
bed  in  a  closed  room,  resulting  usually  in  a  serious  diminution  of  appetite. 

It  is  not  so  much  a  question  of  keeping  the  patient  in  the  open  air  for  a 
certain  number  of  hours  a  day,  nor  yet  of  any  certain  temperature  of  the  air, 
nor  of  this  or  that  form  of  therapy.  The  chief  aim  is  to  create  an  appetite 
and  a  joy  in  living,  and  the  task  in  each  individual  case  is  to  find  the  best 
means  of  doing  this. 

Does  simple  tuberculous  enlargement  of  the  bronchial  lymph  nodes 
require  treatment  if  no  secondary  dissemination  can  be  demonstrated?  If 


746  TEXT-BOOK  OF  PEDIATRICS 

the  child  shows  no  appreciable  symptoms,  other  than  an  occasional  rise  of 
temperature,  does  not  lose  in  weight,  is  not  anemic  and  has  a  good  appetite, 
treatment  is  not  considered  necessary.  (We  believe  it  advisable  to  institute 
dietetic,  as  well  as  climatic  and  solar  treatment  in  all  cases  of  manifest  tubercu- 
lous enlargement  of  the  bronchial  lymph  nodes.)  If,  on  the  other  hand, 
anemia  and  emaciation  are  evident,  associated  with  a  positive  tuberculin 
reaction,  rest  and  dietetic  treatment  are  to  be  recommended,  as  follows :  In 
the  first  week,  absolute  rest  either  in  bed  in  a  well  ventilated  room,  or,  pref- 
erably, in  a  lounge  chair  in  the  open  air.  In  winter  the  patient  should  be 
placed  upon  a  south  veranda;  during  the  summer  a  sunny  garden  will 
better  serve.  He  may  be  allowed  to  play  or  read,  but  regular  study  should 
be  discontinued. 

in  the  second  week,  the  patient  is  permitted  to  get  up  for  a  half-hour 
morning  and  afternoon.  In  the  third  week,  the  periods  of  activity  are 
extended  to  an  hour;  and  in  the  fourth  week  to  two  hours.  While  the  child 
is  up  he  is  allowed  to  play  and  to  run  about,  but  short  of  actual  tire. 

After  the  first  month,  a  modified  form  of  treatment  is  continued  for 
four  to  eight  weeks.  The  child  is  kept  out  of  school;  he  is  given  his  break- 
fast in  bed ;  takes  an  hour 's  rest  in  the  afternoon ;  and  retires  at  eight  o  'clock. 

During  the  entire  course  of  treatment,  the  appetite  must  be  closely 
watched.  It  is  well  to  give  a  bitter  tonic  at  noon  and  at  night.  The  follow- 
ing prescription  has  proved  useful : 

R          Tincturae  ferri  pomata  5.0  (3i) 

Tincturae  nucis  vomicae  1.0  (Tt\,xii) 

Tincturse  cinchonse  composita  20.0  (3iv) 
M.  Sig. — Ten  (10)  drops  in  a  teaspoonful  of  sweetened  water,  ten  minutes  before  meals. 

The  child  should  be  taught  to  eat  slowly  and  to  masticate  his  food 
thoroughly.  Five  meals  a  day  should  be  given,  at  breakfast,  forenoon,  noon, 
afternoon  and  evening.  Large  quantities  of  milk,  or  of  milk  and  cocoa,  malt 
extract  in  amount  proportioned  to  the  action  of  the  bowels,  malt  coffee,  etc., 
are  allowed.  If  eggs  do  not  provoke  indigestion,  one  or  two  a  day  may  be 
used.  If  the  appetite  for  solid  food  diminishes  in  consequence  of  the  milk 
feeding,  the  latter  must  be  reduced.  If  the  child  has  any  difficulty  in  going 
to  sleep  at  night,  a  glass  of  milk  may  be  given. 

Care  must  be  taken  to  regulate  the  bowel  movements.  If  constipation 
ensues,  especially  during  the  first  inactive  weeks,  the  menu  may  be  varied 
with  malt  extract,  stewed  fruit  before  breakfast,  etc.,  or  small  doses  of 
laxatives  may  be  given  to  secure  a  bowel  movement  at  least  every  forty- 
eight  hours. 

In  the  beginning  the  temperature  should  be  taken  four  to  eight  times  a 
day,  until  the  form  of  the  fever  curve  or  the  absence  of  fever  has  been  satis- 
factorily determined.  Later,  it  is  enough  to  take  the  temperature  once 
a  day. 

The  patient  should  be  weighed  every  week  and  compared  with  the  av- 
erage weight  of  children  of  the  same  height.  For  example,  according  to 
Cammerer,  at  ten  years,  the  average  height  for  boys  is  130  centimeters 


TUBERCULOSIS  747 

(52  inches),  and  the  average  weight  30  kilos  (66  pounds).  If  the  given  boy 
is  130  centimeters  tall,  but  weighs  only  26  kilos  (57  pounds),  the  con- 
clusion is  that  he  is  four  kilos  or  nine  pounds,  below  normal  and  the 
attempt  should  be  made  to  bring  him  up  to  the  standard.  During  the  first 
month  of  the  rest-cure,  the  results  are  often  very  marked.  Gains  of  a  kilo 
(2.2  pounds),  are  frequently  made,  especially  in  restless,  nervous  children , 
or  in  those  who  have  been  over  ambitious  in  school.  If  no  gain  is  made 
during  the  first  four  weeks,  a  mild  tuberculin  treatment  is  begun  in  the 
second  month. 

The  treatment  of  manifest  tuberculosis  rests  upon  similar  principles.  If 
the  nutrition  demands  it,  the  course  of  rest  and  dietetic  management  is 
is  undertaken.  After  a  certain  period  of  treatment  it  is  better  to  permit 
the  patient  to  be  about  again,  even  if  the  results  are  not  all  that  could  be 
desired.  The  child  does  not  need  to  be  confined  to  bed  continuously  on 
account  of  a  slight  evening  rise  of  temprature  and  he  should  lie  down  only 
when  he  feels  so  inclined.  He  should  sleep  late;  eat  a  hearty  breakfast,  pref- 
erably in  bed,  and  should  be  kept  out  of  doors  as  much  as  possible  during 
the  day.  If  he  moves  about  actively  he  does  not  need  to  be  heavily  clothed 
and  in  the  summer  the  clothing  should  be  as  light  as  possible.  If  the  child 
sleeps  out  of  doors  his  covering  should  be  adapted  to  the  season  and  in 
extremely  cold  weather  hot  water  bottles  may  be  added. 

If  circumstances  will  not  permit  a  general  fresh  air  and  dietetic  therapy, 
as  a  last  resort,  prepared  foods,  remedies  to  stimulate  the  appetite,  iron,  a 
dilute  solution  of  arsenic,  or  creosote  (five  drops  in  sweetened  milk  twice  a 
day),  may  be  employed.  A  favorite  prescription  follows: — • 

!$  Creosoti 0.5 

Oleii  Morrhusc 100.0 

M.  Sig. — One  teaspoonful,  twice  a  day. 

We  saw  the  Rollier  treatment  carried  out  at  the  Kinderspital  under  Dr. 
Feer  and  believe  it  should  constitute,  if  possible,  part  of  the  treatment  of 
tuberculosis  of  the  glands,  joints  and  bronchial  glands.  The  general  tonic 
effect  is  so  marked  upon  these  children  that  recovery  is  more  speedy 
and  permanent. 

In  unilateral  pulmonary  infection,  Forlanini  's  method  of  nitrogen  in- 
sufflation is  now  frequently  used.  The  thoracic  wall  is  punctured  with  a 
trocar  about  15  cm.  long,  at  a  point  where  there  are  no  adhesions.  A  nickel 
tube,  about  2  cm.  in  diameter,  with  lateral  openings  at  the  rounded  tip,  is 
passed  through  the  trocar.  This  tube  is  attached  to  a  three-way  stopcock 
which  leads  through  rubber  tubing  to  a  manometer  and  to  a  nitrogen  reser- 
voir. The  manometer  reading  is  first  taken  to  show  by  the  negative  pressure 
that  the  point  is  actually  in  the  pleural  cavity.  The  stopcock  is  then  turned 
to  admit  the  nitrogen.  At  the  first  sitting  no  more  nitrogen  should  be 
passed  into  the  cavity  than  will  equalize  the  pressure,  this  will  require, 
according  to  the  age  of  the  patient,  from  300-600  c.c.  Physical  and  fluoro- 
scopic  examination  will  show  that  the  lung  begins  to  expand  again  after  a 
few  days.  When  this  occurs,  nitrogen  is  again  given  and  is  repeated  prob- 


748  TEXT-BOOK  OF  PEDIATRICS 

ably  every  three  or  four  weeks.    This  treatment  requires  several  months. 
It  should  be  discontinued  when  the  expanding  lung  shows  improvement. 

After  the  use  of  nitrogen,  the  temperature  usually  falls.  Hemoptysis 
ceases,  the  expectoration  is  diminished,  and  the  appetite  improves  although 
there  is  no  great  gain  in  weight  during  the  treatment. 

Even  young  children  stand  the  pneumothorax  well.  In  these  cases,  the 
operation  should  be  performed  under  general  anesthesia  in  order  to  avoid 
the  errors  in  manometer  reading  which  may  result  from  the  struggling  of 
the  child.  The  operation  may  be  complicated  by  the  development  of  em- 
physema of  the  skin  or  serous  pleuritis.  There  is  no  danger  of  air  emboli 
if  the  manometer  is  carefully  watched. 

In  severe  phthisis,  in  brain  tuberculosis,  or  in  painful  intestinal  tuber- 
culosis, hypnotics  and  narcotics  should  be  given  freely.  Morphin  may  be 
used  by  mouth  or  hypodermically. 

There  remains  the  tuberculin  method  of  treatment.  As  in  the  matter  of 
general  therapy,  it  is  of  chief  use  in  chronic  tuberculosis  and  not  in  the  acute 
pulmonary  affections  of  young  children,  nor  in  the  intense  manifestations 
of  scrofulous  disease. 

The  method  of  tuberculin  treatment  is  as  follows : 

Three  dilutions  of  1 : 10,000;  1 : 100,000  and  1 : 1,000,000  of  old  tuberculin 
are  prepared  in  fresh  sterile  physiologic  salt  solution.  The  treatment  is 
begun  with  one  millionth  of  a  gram  (one  rnicromilligram) .  One  cubic  cen- 
timeter of  the  1:  1,000,000  solution  is  drawn  into  a  10  c.c.  syringe,  and  to 
this  is  added  9  c.c.  of  sterile  physiologic  salt  solution.  This  preparation  is 
injected  subcutaneously  in  the  back.  The  first  injection  should  be  given 
in  the  upper  region  and  each  succeeding  injection  a  few  centimeters  lower 
down.  The  dilution  of  tuberculin  with  a  large  quantity  of  physiologic  salt 
solution  (10-20  c.c.),  is  to  be  preferred  to  the  use  of  more  concentrated 
solutions,  since  the  former  causes  less  local  reaction  (Herbert  Koch). 

After  an  interval  of  three  days,  the  next  stronger  dilution  is  given  and 
after  four  days  more  the  third  dilution,  and  so  on.  Two  injections  should 
be  given  each  week.  The  dose  is  increased  in  geometric  progression,  as  10, 
15,  22,  32,  47,  68,  100,  unless  fever  ensues.  In  that  event  the  identical  dose 
should  be  repeated.  If  this  dose  again  causes  fever,  the  next  dose  should 
be  reduced.  If  fever  continues  to  appear  the  treatment  should  be  stopped. 

In  the  majority  of  instances,  however,  the  gradual  increase  is  borne  with- 
out fever.  In  three  weeks  time,  a  dose  of  ten  micromilligrams  is  reached; 
in  six  weeks  a  dose  of  one  hundred;  and  in  nine  weeks  of  one  milligram. 
Thereafter,  six  more  injections  of  one  milligram  each  are  given,  after  which 
treatment,  having  continued  for  three  months,  may  be  considered  complete. 

The  scrofula  of  the  poor  is  most  favorably  influenced  if  the  child  can  be 
removed  from  the  home  environment  for  several  months  and  placed  in 
healthy  surroundings  with  the  opportunity  of  proper  care  and  a  good 
dietary.  If,  with  these  conditions,  open  air  treatment  at  the  seashore  or  in 
the  mountains  can  be  combined,  the  results  are  more  favorable.  Benefit 
may  be  secured,  however,  in  other  sunny  places  which  are  free  from  dust 


TUBERCULOSIS  749 

and  smoke.  Ocean  baths,  sun-baths  or  bathing  in  iodine-containing  spring 
water  (Halle),  are  especially  efficacious  in  scrofulous  cases. 

In  the  home,  improvised  baths  may  be  given  once  or  twice  a  week. 
Two  kilos  (5  pounds),  of  rock  salt  are  dissolved  in  fifty  litres  (12  gallons), 
of  warm  water.  The  child  should  remain  in  this  bath  for  ten  minutes,  the 
water  being  kept  at  26°  C.  (97°  F.).  The  patient  should  be  kept  in  bed  for 
two  hours  after  the  bath  or  it  may  be  given  instead  at  bedtime.  Inunction 
with  soft  soap  (sapo  viridis),  three  times  a  week  may  be  employed  as  a 
substitute  for  the  sun-bath  treatment.  Twenty  grains  (%  ounce)  of  the 
soap  may  be  rubbed  over  the  back  and  abdomen.  It  is  left  in  place  for  ten 
to  thirty  minutes  and  is  then  carefully  washed  off. 

Medically,  cod-liver  oil,  with  1  per  cent,  of  creosote,  or  large  quantities 
of  iodine-  and  iron-containing  water  may  be  recommended.  Neither  iodine, 
iron  or  arsenic  have  any  specific  action  upon  tuberculosis.  Their  favorable 
influence  is  to  be  attributed  to  their  effect  upon  the  metabolism. 

The  tuberculin  treatment  has  not  given  any  real  results  in  scrofulous 
affections.  The  field  of  this  method  lies  in  chronic  tuberculosis,  in  which 
there  is  but  small  power  of  reaction,  as  in  infection  of  the  lung  apices  or  in 
tuberculosis  of  the  larger  bones.  It  is  doubtful  that  any  particular  dietary 
can  induce  symptoms  of  scrofula  in  the  tuberculous.  That  children  of  the 
poor  are  more  commonly  affected  seems  to  indicate  that  it  is  not  so  much  a 
question  of  wrong  feeding  or  even  of  underfeeding,  as  it  is  one  of  poor 
hygienic  surroundings. 

In  local  tuberculosis,  surgical  interference  is  indicated  symptomatically; 
but  it  should  be  undertaken  only  after  we  are  assured  that  there  is  no  pro- 
gress toward  recovery.  Surgeons  are  becoming  more  conservative  year  by 
year  in  their  treatment  of  tuberculosis.  Special  warning  should  be  given 
against  the  total  excision  of  indurated  lymph  nodes,  of  fungus  joints,  or  of 
fingers  with  spina  ventosa,  etc.  The  long  expectation  of  spontaneous  re- 
covery doubtless  requires  great  patience,  but  large  experience  is  necessary 
to  enable  one  to  predict  that  it  will  take  place  without  interference. 


X. 

SYPHILIS 

BY 
ERNST  MORO, 

Heidelberg. 
REVISED  AND  EDITED  BY 

PHILIP  C.  JEANS,  M.  D., 

Associate  Professor  of  Pediatrics, 
Washington  University  School  of  Medicine,  St.  Louis. 

ETIOLOGY  AND  NATURE 

SYPHILIS  is  caused  by  the  spirochseta  pallida,  discovered  by  Schaudinn 
in  1905.  Spirochsetes  are  considered  by  some  as  allied  to  bacteria,  by  others 
as  of  protozoan  nature,  and  by  still  others  as  differing  from  both  bacteria 
and  protozoa  and  classed  in  the  domain  of  the  protista.  The  situation  is 
still  much  confused.  Because  of  the  confusion  in  classification,  there  is  an 
uncertainty  as  to  the  proper  name  by  which  to  designate  the  organism. 
Some  excellent  systematists  prefer  the  name  triponema  pallidum  rather 
than  spirochceta  pallida.  As  it  stands  at  present,  these  two  names  may  be 
used  interchangeably.  (Vid.,  Noguchi,  Am.  Jour.  Syphilis,  1:261,  1917.) 
The  spirochseta  pallida  is  classed  as  a  protozoan  and  is  an  extremely  delicate 
thread-like  organism,  with  tapering  ends  and  with  length  varying  from  four 
to  fourteen  micromillimeters.  Its  corkscrew-like  convolutions  are  rigid, 
short  and  acute.  In  some  specimens  twenty  or  more  such  convolutions  are 
seen,  but  usually  they  are  less  numerous — a  difference  which  may  be  due  to 
the  tearing  of  the  threads  in  preparation.  Fresh  pallid®  are  actively 
motile,  twisting  in  their  longitudinal  axis  or  moving  forward  or  backward. 
Frequently  two  or  more  specimens  are  seen  lying  side  by  side.  The  Y- 
shaped  figures  they  present,  probably  indicate  the  process  of  generation  by 
division.  The  various  types  of  systematically  related  spirochaetse  may  be 
distinguished  by  their  greater  thickness,  their  smaller  number  of  convolu- 
tions, their  blunter  poles  and  their  variable  readiness  of  reaction  to  the 
analin  stains. 

In  the  smear  the  spirochsetae  are  most  readily  and  certainly  demonstrated 
by  Burri's  method,  as  follows:  A  small  quantity  of  the  material  to  be 
examined,  preferably  in  the  form  of  serum  taken  from  a  lesion,  is  placed 
upon  a  slide  and  one  or  two  loopfuls  of  ordinary  liquid  India  ink,  from  which 
the  larger  particles  have  been  removed  by  centrifuging  for  half  an  hour,  are 
added.  The  black  drop  is  then  spread  in  a  thin  layer,  as  in  the  making  of 
blood  spreads,  with  the  edge  of  a  second  slide.  The  preparation  is  dried  in 
750 


SYPHILIS 


751 


the  air  and  examined  under  the  oil-immersion  lens.  The  spirochaeta  and 
other  corpuscular  elements  remain  unstained  and  stand  out  prominently 
upon  the  black  background.  The  organism  has  recently  been  cultured, 
(Sowadi  Noguchi),  but  the  process  is  not  of  practical  use.  Recently  the 
method  of  dark  field  illumination  has  almost  entirely  superseded  the  older 
methods  of  demonstrating  the  spirochsetae. 

The  human  being  responds  to  infection  with  the  spirochseta  pallida  by 
the  formation  of  distinct  antibodies.  Very  little  is  known  concerning  the 
nature  of  these  antibodies,  but  it  seems  fairly  well  established  that  the 
clinical  reaction  of  the  human  subject  to  the  organism  stands  in  very  close 
relationship  to  the  activity  of  the  formed  antibodies.  This  is  the  only 
way  in  which  the  long  and  fairly  constant  incubation  period  which  elapses 
between  the  date  of  infection  and  the  appearance  of  the  primary  lesion 
can  be  explained.  It  also  affords  a  satisfactory  explanation  of  the  change 
which  the  once  infected  organism 
undergoes  and  which  persists  for  the 
rest  of  life.  This  change  is  evidenced 
in  a  number  of  ways,  but  chiefly  in 
the  fact  that  a  subsequent  reinfection 
of  the  syphilitic  patient  with  virulent 
material,  is  either  altogether  negative 
or  causes  a  mild,  abortive  and  more 
transitory  reaction  than  it  did  the  first 
time.  This  statement  applies  only  to 
those  who  have  had  insufficient  treat- 
ment. According  to  current  opinion, 
syphilis  may  be  cured  in  many  in- 
stances and  in  such  a  case,  a  reinfec- 
tion behaves  as  did  the  first  one.  In 
the  test-tube  only  one  substance 
representing  these  antibodies  and  re- 
acting  in  this  manner  has  been  so  far 

recognized.  This  circulates  freely  in  the  blood  and  is  characterized  by  its 
marked  affinity  for  lipoid  substances,  of  human  and  animal  origin,  soluble  in 
alcohol.  As  a  consequence  of  this  characteristic,  it  has  come  to  be  regarded 
as  a  specific  reagent  of  great  significance  in  the  diagnosis  of  syphilis. 

As  in  many  other  infections,  the  picture  which  the  disease  presents  to  us, 
is  one  of  the  defense  of  the  organism  against  the  antigens.  As  an  actual 
fact,  the  defensive  material,  which  the  human  subject  can  bring  to  bear 
against  the  attack  of  the  spirochaeta,  is  adequate  to  the  complete  destruction 
of  the  parasite  in  only  very  exceptional  cases.  Foci  of  infection  may  develop 
repeatedly  and  repeatedly  stimulate  the  organism  to  the  formation  of  new 
antibodies,  so  that  an  almost  continuous  reaction  between  the  antigens 
and  the  antibodies  is  maintained  and  produces  the  picture  of  a  chronic 
infectious  disease. 

In  this,  as  in  many  other  respects,  the  course  of  syphilis  resembles  that 
of  tuberculosis.  In  both  diseases,  the  primary  lesion  develops  at  the  point 


FlG.  192._smear  of  fluid  from  luetic  papule 
'm  aninfant)-  India 


752  TEXT-BOOK  OF  PEDIATRICS 

of  entry  of  the  antigen  after  a  latent  period  of  long  duration,  wholly 
devoid  of  symptoms.  In  both  cases,  again,  the  lymph  nodes  in  the  neighbor- 
hood of  the  primary  focus  become  diseased  in  a  specific  manner.  Path- 
ogenetically,  therefore,  the  syphilitic  bubo  is  analogous  to  the  diseased 
bronchial  node,  which  represents  the  regional  result  of  tuberculosis  in  the 
lung  tissue.  Almost  coincidently  with  the  appearance  of  the  initial  focus, 
the  change  of  the  organism  or  allergy,  reacting  to  the  antigen,  is  completed 
alike  in  both  diseases.  The  organism  has  become  Irypersensitive  toward  the 
specific  infection.  This  hypersensibility  gives  a  peculiar  prominence  to  all 
the  succeeding  phases  of  the  reaction  and  is  responsible,  therefore,  to  a  large 
extent  for  the  clinical  character  of  the  so-called  secondary  and  tertiary 
manifestations  of  the  disease.  From  this  point  of  view,  the  typical  exanthe- 
mata and  the  lesions  of  the  mucous  membranes  in  the  secondary  stage  of 
syphilis,  would  correspond  to  the  manifold  integumental  and  catarrhal 
reactions  of  tuberculosis;  while  the  gummata,  characteristic  of  the  tertiary 
stage  with  its  distinct  tendency  to  necrotic  destruction,  correspond  to  the 
rapidly  progressing  ulcer  formation  of  so-called  phthisis. 

Emphasis  must  be  put  at  once  upon  the  fact  that  this  comparison  holds 
good  for  acquired  syphilis  alone.  In  congenital  syphilis,  with  which  this 
discussion  is  chiefly  concerned,  entirely  different  conditions  often  obtain. 

In  the  first  place,  the  primary  lesion  is  lacking  in  the  great  majority  of 
cases,  since  the  initial  infection  of  the  fetus  occurs,  as  will  be  seen  later, 
through  the  blood.  This  circumstance  is  doubtless  an  important  factor  in 
infantile  syphilis.  To  this  is  to  be  added  the  fact,  that  in  the  fetus  and  the 
young  infant  the  formation  of  antibodies  is  very  slow  and  hence  there  is  no 
effective  bar  to  the  increase  and  the  spread  of  the  spirochseta.  Very  often 
the  antigen  antibody  reactions  alluded  to  do  not  occur  and  the  defenseless 
organism  remains  passive  until  it  is  overrun  and  fairly  strangled  by  the 
disease  parasites.  Nevertheless,  relatively,  the  simile  holds  good,  for  in 
fetal  tuberculosis,  the  tubercle  bacillus  is  planted  in  an  organism  wholly 
unable  to  defend  itself. 

MODES  OF  INFECTION 

Infection  with  the  spirochseta  pallida  takes  place  either  before,  during, 
or  after  birth.  If  it  occurs  during  intra-uterine  life  or  during  parturition  it  is 
termed  congenital  syphilis;  if  at  any  other  time,  acquired  syphilis.  Infec- 
tion before  birth  is  by  far  the  more  frequent  event  and  is  the  most  important 
source  of  syphilis  in  children.  The  infection  of  the  fetus  with  the  spiro- 
chseta always  comes  from  the  mother  and  from  the  mother  alone.  She  may 
be  infected  before,  during,  or  after  conception.  The  spirochsetse  circulate 
in  her  blood  and  reach  the  placenta,  where  they  cause  specific  changes; 
the  organ  becoming  diseased  and  permeable  to  the  parasites  and  the  fetus 
being  thereby  infected.  The  possibility  of  paternal  transmission  without 
infection  of  the  mother  is  still  debated.  Though  the  weight  of  evidence 
is  in  favor  of  the  statement  as  here  made,  no  absolute  proof  has  yet 
been  advanced. 

The  infection  of  the  fetus  may  occur  at  any  time  during  pregnancy.    The 


SYPHILIS  753 

earlier  the  infection  takes  place  the  smaller  are  the  chances  that  the  fetus 
will  live.  If  it  be  possible  for  a  spermatozoon  to  fertilize  a  previously 
infected  ovum,  there  would  be  no  probability  of  its  further  development. 
Such  an  ovum  must  die.  On  this  account,  the  so-called  paternal  syphilis, 
a  term  which  implies  that  the  spirochaeta  reaches  the  ovum  through  the 
spermatozoon  or  through  the  spermatic  fluid,  when  the  mother  is  un- 
infected,  cannot  be  given  serious  consideration  in  the  pathogenesis  of  the 
congenital  form  of  the  disease. 

These  views  regarding  the  transmission  of  congenital  syphilis  through 
the  placenta  are  simple  and  easy  of  acceptance.  Nevertheless,  the  long 
recognized  fact  that  mothers  of  syphilitic  children  very  often  show  not  the 
slightest  trace  of  syphilis  and  remain,  to  all  appearances,  immune  to  the 
disease  all  their  life  long,  is  an  extremely  peculiar  and  remarkable  one.  No 
exceptions  to  the  persisting  immunity  of  such  cases,  demonstrated  by 
Colles  and  Baumes,  are  recorded;  and  accordingly  it  has  become  a  justly 
recognized  rule  and  is  known  as  Colles '  law.  It  means  that  a  mother  who 
gives  birth  to  a  syphilitic  child  and  shows  no  symptoms  in  herself  of  the 
disease,  is  and  remains  immune  to  syphilis.  Gaucher  records  a  case 
of  an  hereditary  syphilitic  infant  infecting  its  mother.  Such  cases  are  so 
rare  that  a  mistake  in  history  or  observation  may  be  suspected  in  this  one. 
(Gaucher:  Ann.  des.  mal.  ven.  11:1  Jan.,  1916. 

In  the  past  a  large  number  of  theories  have  been  advanced  to  explain 
Colles'  law.  The  principal  one  among  them  proposed  that  immune  sub- 
stances from  the  fetus,  infected  from  the  spermatozoon,  pass  over  to  the 
mother  and  confer  a  lasting  protection  upon  her,  so  that  she  remains 
healthy.  Conceding  that  the  fetus,  unable  to  protect  itself,  is  yet  able  to 
form  so  active  an  immune  substance ;  and  conceding  further  that  these  sub- 
stances can  then  pass  through  the  placenta  and  become  the  property  of  the 
mother,  it  still  seems  highly  improbable  that  such  a  passive  acquired  im- 
munity can  be  at  all  permanent.  This  doubt  is  very  definitely  justified  by 
numerous  examples  of  research  in  artificial  immunity.  An  immunity  con- 
ferred by  the  mother  upon  the  child  hardly  ever  lasts  more  than  a  few 
months  and  the  converse  is  probably  equally  true.  The  possibility  that 
syphilis  antigens  in  the  form  of  toxins  are  carried  from  the  infected  fetus  to 
the  healthy  mother  is,  of  course,  not  wholly  deniable.  Under  such  circum- 
stances active  immunity  of  unlimited  duration  might  be  established  in 
the  mother.  Still  not  a  vestige  of  proof  has  been  brought  forward  to  sup- 
port such  a  theory. 

The  mother  of  the  syphilitic  child  is  immune  to  syphilis  because  she 
herself  has  been  infected;  an  unanswerable  postulate  of  the  theory  of  ma- 
ternal heredity  and  a  strong  support  of  its  conclusions.  Furthermore,  a 
large  percentage  of  reaction  bodies  has  been  found  in  the  blood  of  mothers 
free  from  any  clinical  evidences  of  syphilis,  but  having  syphilitic  children. 
The  maternal  side  of  the  placenta  frequently  harbors  spirochsetse. 

The  so-called  Profeta's  law,  which  holds  that  the  healthy  child  of  a 
recently  luetic  mother  is  protected  against  syphilitic  infection,  that  is, 
that  the  child  is  immune  to  syphilis,  has  little  foundation.  Very  probably 
48 


754  TEXT-BOOK  OF  PEDIATRICS 

such  children  are  actually  infected,  but  with  luetic  symptoms  so  slight  as  to 
be  overlooked.  A  positive  Wassermann  reaction  is  obtained  in  all  such 
children  and  is  accepted  as  evidence  that  they  have  been  infected. 

Strange  and  inexplicable,  indeed,  is  the  fact  that  the  syphilis  of  mothers 
of  syphilitic  children  is  so  frequently  devoid  of  symptoms.  It  is  not  sur- 
prising that  the  primary  lesion  or  the  bubo  should  be  hidden.  These  may  be 
situated  in  some  part  of  the  uterus  and  in  the  lymph  nodes  of  that  imme- 
diate region.  But  that  such  mothers  should  so  rarely  show  secondary  or 
tertiary  manifestations  and  that  they  should  so  frequently  enjoy  the  best  of 
health  throughout  life  is  extraordinary  indeed.  There  would  seem  to  be  no 
doubt  that  the  special  metabolic  conditions  so  closely  related  to  the  develop- 
ment and  bearing  of  a  syphilitic  child  play  some  part  in  these  results. 

Infection  during  birth  is  very  uncommon  and  particularly  hard  to 
prove.  It  can  be  accepted  as  probable  only  when  the  new-born  child  shows 
a  typical  primary  lesion  several  weeks  after  birth.  Several  instances  have 
been  reported  in  which,  within  the  first  month,  a  typical  initial  lesion  ap- 
peared at  the  base  of  the  nose  in  a  child  being  born  with  a  face  presentation 
of  a  recently  syphilized  mother  who  showed  a  fresh  genital  chancre.  Even  in 
these  cases,  of  course,  infection  after  birth  cannot  be  positively  excluded. 

It  may  be  that  the  loosening  and  compression  and  the  partial  separation 
of  the  placenta  during  labor  may  be  held  responsible  for  the  passage  of  the 
spirochaeta  from  the  placenta  to  the  fetal  blood.  Doubtless,  the  protecting 
epithelium  of  the  chorion  may  become  ruptured  during  this  process  and 
the  blood  of  the  mother  and  of  the  fetus  may  then  communicate  directly. 
Rietschel  lays  great  stress  upon  this  intra-partum  mode  of  infection  and 
claims  that  it  explains  the  fact  that  children  of  syphilitic  mothers  are  so 
frequently  born  without  any  clinical  signs  of  the  disease,  these  appearing 
only  after  some  weeks.  This  latent  period  would  then  correspond  to  the 
specific  incubation  period  of  the  disease. 

Infection  of  healthy  children  after  birth  may  occur  in  a  number  of  ways. 
This  phase  is  discussed  upon  page  785  under  the  Acquired  Syphilis  of 
Children. 

I.  CONGENITAL  SYPHILIS 

Congenital  syphilis  is  usually  described  under  two  heads:  fetal  syphilis 
and  infantile  syphilis.  Actually,  there  is  no  conclusive  reason  for  the 
definite  distinction  of  these  two  conditions,  for  excepting  in  the  event  of 
intra-partum  infection,  infantile  syphilis  presents  nothing  more  than  a  direct 
continuation  of  the  disease  acquired  during  fetal  life  to  postnatal  life.  As 
will  be  seen,  this  is  especially  true  of  syphilis  of  the  internal  organs.  For 
this  reason,  Heubner  very  properly  speaks  of  the  "projection  of  fetal  vis- 
ceral syphilis  into  infancy."  Moreover,  the  pathology  of  syphilis  in  the 
two  phases  of  its  development  has  such  identical  characters  that  a  separate 
discussion  seems  out  of  place  on  didactic  grounds.  Perhaps  the  fact  that, 
for  obvious  reasons,  the  study  of  fetal  syphilis  lies  entirely  with  the  pathol- 
ogist, while  the  syphilis  of  infancy  constitutes  one  of  the  most  deeply 
studied,  serious  and  stimulating  subjects  in  clinical  pediatrics,  may  have 
served  as  a  reason  for  the  division. 


SYPHILIS  755 

FETAL  SYPHILIS 

The  spirochseta  very  evidently  finds  the  fetal  organism  a  rich  soil.  As 
already  intimated,  a  reason  for  this  is  to  be  found  in  the  inherent  lack  of 
fetal  defense — in  the  absence  of  the  natural  agencies  of  protection  in  the 
tissues  of  the  fetus.  Thus  it  happens  that  in  extreme  cases  all  the  fetal 
organs  are  literally  choked  with  the  parasites.  The  inevitable  results  are 
seen  in  the  frequent  death  of  the  fetus  in  utero  and  the  syphilitic  abortion 
in  which  the  fetus  is  cast  off  dead  and  macerated.  This  maceration  of  the 
fetus  is  highly  characteristic  of  syphilis.  Graefenberg  found  the  spirochseta 
in  80  per  cent,  of  all  fetuses  that  were  macerated  when  expelled.  Syphilitic 
abortion  is  most  common  in  recent  and  untreated  lues;  it  occurs  chiefly 
in  the  fourth  and  the  seventh  months  of  pregnancy,  although  it  may  be 
met  with  at  other  periods.  If  the  mother's  history  shows  a  succession  of 
habitual  abortions,  syphilis  must  always  be  suspected. 

The  structural  changes  are  not  very  typical  in  the  first  few  months,  or 
even  in  the  first  half  of  pregnancy.  Diffuse  cell  proliferation;  active  prolif- 
erative  processes;  increased  volume  and  consistency  of  the  cells;  a  very 
active  development  and  differentiation  of  organs,  now  infected,  can  be 
demonstrated  in  normal  fetuses  at  this  period.  The  discovery  of  the  spiro- 
cha3ta  at  this  time  is  rare.  In  all  probability  the  death  of  the  embryo  is 
directly  caused  by  the  usual  disease  of  the  placenta,  which  shows  vascular 
changes,  scar  formation,  and  contraction  of  the  villi.  The  attack  upon 
the  placenta  leads  to  the  innutrition  of  the  fetus  incident  to  the  insuf- 
ficient supply  of  food  material  from  the  maternal  to  the  fetal  vessels. 

In  the  second  half  of  pregnancy,  on  the  contrary,  the  syphilitic  changes 
in  the  fetal  organs  are  commonly  distinct.  Two  processes,  indeed,  standout 
most  prominently:  1.  Diffuse  cell  infiltration;  2.  Retardation  of  growth. 

1.  Diffuse  cell  infiltration  does  not  develop  to  the  extent  seen  in  the 
syphilis  of  children  in  any  other  period.     Macroscopically,  the  condition 
results  in  a  marked  increase  in  the  mass  and  the  consistency  of  the  affected 
organs  alone.    This  is  seen  chiefly  in  the  liver  and  the  spleen.    The  micro- 
scope, however,  shows  that  this  process  is  general  and  that  almost  all  the 
viscera — the  kidneys,  lungs,  pancreas,  thymus,  and  the  osseous  system,  as 
well  as  the  liver  and  the  spleen,  are  affected  in  practically  the  same  manner. 

The  cellular  increase  has  its  origin  in  the  interstitial  connective  tissue 
lying  around  the  smallest  blood-vessels.  In  advanced  cases,  the  prolifer- 
ative  process  may  become  so  intense  as  to  result  in  veritable  masses  of  cells, 
recognized  even  macroscopically,  which  have  been  called  miliary  syphib- 
mata.  Large  numbers  of  spirochsetse  are  found  in  the  proliferated  peri- 
vascular  tissues.  In  a  later  stage  the  hypertrophied  connective  tissues  show 
a  distinct  tendency  to  retraction. 

2.  The  cell  proliferation  delays  the  visceral  development.     The  far- 
reaching  hyperplasia  of  the  interstitial  connective  tissue  stands  in  direct 
contrast  to  the  marked  hypoplasia  of  the  parenchyma. 

Small  remnants  of  parenchyma,  developed  at  an  earlier  period,  are 
often  found  in  the  midst  of  the  interstitial  cell  infiltration,  as  foci-like  agglom- 


756  TEXT-BOOK  OF  PEDIATRICS 

erations  of  cylindrical  or  cubical  cells,  or  as  entire  epithelial  tubes,  etc. 
In  the  lung,  an  intense  desquamation  of  alveolar  epithelium,  undergoing 
fatty  degeneration,  will  occur  into  the  lumen  of  the  alveoli,  accompanying 
the  proliferation  of  the  underlying  connective  tissue.  As  a  result,  the  cut 
surface  has  a  peculiar  homogeneous,  whitish-yellow  appearance,  the  so- 
called  white  pneumonia.  Wholly  similar  processes  may  occur  in  the 
thymus,  making  this  organ  look  as  though  it  were  filled  with  numerous 
cysts  filled  with  a  pus-like  secretion.  This  general  retardation  of  growth 
and  development  is  the  coincident  cause  of  the  almost  invariably  low  body- 
weight  and  the  small  size  of  syphilitic  premature  infants  as  compared  with 
normal  children  of  the  same  period.  This  abnormally  low  weight  is  all  the 
more  remarkable  since  these  children  show  a  considerable  increase  in  the 
mass  of  the  internal  organs. 

Another  notable  fact  is  that  the  skin,  the  organ  which  later,  with  syphi- 
litic infants,  plays  so  important  a  role  in  the  clinical  history,  usually  remains 
unimpaired  in  fetal  life.  Now  and  then  an  infected  child  is  born  with  a 
syphilitic  eruption,  the  ominous  papular  pemphigus.  Other  skin  manifesta- 
tions always  appear  later.  Hochsinger  explains  this  peculiar  difference  of 
the  intact  skin  and  the  notable  visceral  involvement  during  fetal  life,  as  due 
to  the  relatively  late  glandular  development  of  the  skin  and  the  early 
differentiation  and  rapid  growth  of  the  internal  organs  in  utero.  The 
syphilitic  poison  is  supposed  to  possess  a  special  affinity  for  highly  vascu- 
larized  tissues.  It  might  be  expected  that  the  cutaneous  surface,  subject 
to  suddenly  increased  irritation  by  the  stimuli  of  extra-utrine  life,  would 
be  the  more  disposed  thereby  to  exthanthematous  eruptions.  Nevertheless, 
it  is  a  fact  that  those  tissues  in  which  the  most  active  growth  obtains,  as  at 
the  boundary  lines  of  bone  and  cartilage,  succumb  in  most  characteristic 
manner,  even  during  fetal  life,  to  the  disease.  This  seems  to  indicate  the 
probable  relationship  of  a  formative  stimulus,  as  suggested  by  Hochsinger, 
between  the  syphilitic  process  and  the  process  of  tissue  differentiation. 

The  inflammation  at  the  margin  between  bone  and  cartilage,  a  syphi- 
litic osteochondritis,  first  accurately  described  by  Wegner,  is,  with  the 
exception  of  splenic  enlargement,  the  most  constant  and  the  most  easily 
demonstrable  sign  of  congenital  lues.  It  occurs  chiefly  at  the  ends  of  all 
the  long  bones  and  at  the  anterior  extremities  of  the  ribs. 

Microscopically  it  may  be  seen,  in  longitudinal  section,  that  the  osteo- 
chondral  boundary,  normally  marked  by  a  whitish  line  hardly  a  half 
millimeter  in  thickness,  is  widened.  It  may  measure  two  millimeters  or 
more.  This  line,  moreover,  has  a  yellowish  tinge  and  is  no  longer  of  regular 
width,  but  presents  a  jagged  outline,  the  toothpoints  extending  into  the 
cartilage.  In  advanced  stages,  a  peculiar  grating  is  noticed  as  the  knife 
passes  through  the  tissue,  feeling  as  though  it  were  in  contact  with  fine 
particles  of  lime  or  mortar.  A  small  section  of  this  hard  substance  may  be- 
come loosened  and  fall  out. 

These  impressions  in  the  gross  are  fully  supported  and  explained  by  the 
microscope.  The  entire  process  is  confined  to  the  zone  of  temporary  calci- 
fication. The  area  is  abnormally  wide.  The  calcification,  though  irregular, 


SYPHILIS  757 

proceeds  rapidly,  but  resorption  is  delayed.  The  transition  to  bone  does  not 
take  place,  since  the  osteoblasts  lack  the  bone-forming  elements  and 
actually  constitute  a  useless  granulation  tissue.  The  irregular  border  is  due 
to  the  persistence  of  calcified  remnants  of  cells,  and  the  yellow  color  to  a 
more  or  less  characteristic  granulation  tissue,  through  which  typical  syphi- 
litic changes  in  the  form  of  small  gummatous  masses  may  be  scattered.  In 
consequence  of  these  departures,  the  ordinary  formation  of  anastomoses 
between  the  irregular  newly-formed  bone-platelets  is  lacking.  This  granu- 
lation tissue  is  entirely  cut  off  from  its  blood  supply  and  this  occurs  all  the 
earlier  if  the  syphilitic  inflammation  is  very  active.  As  a  further  result,  the 
continuity  of  the  scaffold  of  the  bone-platelets  is  not  only  weakened,  but 
may  be  completely  destroyed,  and  the  separation  of  the  diaphysis  from  the 
epiphysis  in  the  zone  of  calcification  finally  ensues. 

Such  extremes  of  visceral  change  as  this  cannot,  of  course,  be  found  in 
every  case  of  fetal  syphilis.  In  case  of  difficulty  in  the  matter  of  diagnosis, 
the  problem  may  be  solved  oftentimes  most  readily  by  the  histologic 
examination  of  the  kidneys.  Hecker  found,  in  90  per  cent,  of  his  cases, 
specific  renal  changes,  especially  in  the  form  of  small  cell  infiltration  around 
the  cortical  vessels.  Others  claim,  on  the  contrary,  that  this  organ  is  the 
best  preserved  in  macerated  fetuses.  In  doubtful  cases  it  is  often  possible 
to  demonstrate  spirochsetse.  For  their  discovery  the  umbilical  cord  and 
the  adrenals,  seats  of  election,  must  be  studied.  Spirochaetae  are  said  to  be 
especially  numerous  near  the  fetal  insertion  of  the  former. 

INFANTILE  SYPHILIS 

In  the  infant,  congenital  syphilis  manifests  itself  either  immediately 
after  birth  or  within  the  first  weeks  of  postnatal  life.  Not  infrequently  the 
disease  becomes  clinically  apparent  only  within  the  second  month.  Of  the 
clinical  signs  with  which  syphilitic  infants  are  born,  three  are  especially 
prominent  and  characteristic:  1.  Coryza.  2.  Pustular  eruption  on  the 
hands  and  feet.  3.  Enlargement  of  the  spleen. 

These  three  symptoms  form  a,  by  no  means,  constant  triad.  At  times 
they  occur  coincidently.  In  a  child  with  pemphigus,  the  splenic  tumor  is 
hardly  ever  absent,  but  each  symptom  is  so  significant  in  itself,  that  its 
presence  at  least  demands  a  further  inquiry.  With  congenital  pemphigus 
on  the  hands  and  feet  every  diagnostic  doubt  is  laid. 

1.  Coryza  or  syphilitic  rhinitis  is  indicated,  at  first,  like  every  other 
coryza,  by  embarrassed  nasal  respiration.  The  nostrils  are  narrowed  and 
plugged.  A  peculiar  snuffling,  with  the  passage  of  air,  results.  This  is  often 
discernible  at  a  distance.  Naturally  great  difficulty  results  in  getting  such 
children  to  nurse. 

Examination  of  the  nose  often  reveals  nothing  more  than  marked  swell- 
ing of  the  nasal  mucous  membrane,  especially  in  the  postnasal  areas.  At 
first  there  is  little  or  no  secretion  and  the  whitish  foamy  mucus  of  ordinary 
coryza  is  never  present.  Later,  as  the  process  develops,  a  purulent,  and,  at 
tunes,  a  bloody  secretion  appears.  Sometimes  the  coryza  subsides  after  a 


758  TEXT-BOOK  OF  PEDIATRICS 

few  weeks,  but  generally  it  is  very  obstinate  and  persists  unvaryingly  for 
a  long  period. 

Of  course  this  symptom  is  not  present  in  all  syphilitic  infants.  Many  of 
them  are  entirely  free  from  coryza.  If  it  does  occur,  it  is  usually  congenital 
or  appears  very  soon  after  birth;  at  the  very  latest  from  the  fourth  to  the 
eighth  week.  This  congenital  coryza  is  usually  so  noticeable  that  the 
mother  never  forgets  it.  If  in  the  history  appears  a  record  of  "snuffles  dur- 
ing the  first  few  weeks, "  it  is  a  cardinal  point  in  the  recognition  of  lues. 

The  well-known  nasal  deformities,  in  the  form  of  pug  nose  or  saddle  nose 
seen  in  syphilitic  infants  may  be  charged  to  this  process.  They  are  conse- 
quent upon  a  severe  rhinitis,  which  may  be  completed  in  early  fetal  life, 
but  leads  to  a  retardation  of  intrinsic  growth  and  of  the  development  of  the 
cartilaginous  and  bony  framework  of  the  nose  (see  Fig.  213). 

2.  Syphilitic  pemphigus  consists  of  vesicles,  varying  in  size  from  that  of 
a  pea  to  that  of  a  cherry,  rising  from  an  inflammatory  base.  Their  content 


FIG.  193. — Syphilitic  pemphigus  of  the  new-born  on  the  soles  of  the  feet. 

is  at  first  serous  and  slightly  cloudy,  but  it  soon  becomes  purulent.  Often 
numerous  spirochsetse  may  be  demonstrated  in  the  fluid.  The  localization 
of  the  eruption  on  the  palms  of  the  hands  and  the  soles  of  the  feet  and  on  the 
plantar  surfaces  of  the  fingers  and  toes  is  highly  characteristic.  The 
syphilitic  pemphigus  is  usually  present  at  birth,  but  it  may  appear  during 
the  first  week  and  more  rarely  during  the  second  to  the  fourth  week.  At 
times  it  is  found  on  other  parts  of  the  body.  The  eruption  never  retains  its 
vesicular  character  for  long.  The  vessels  rapidly  dry  up;  they  crumble  or 
burst,  and  the  bleeding  corium  lies  exposed,  the  site  surrounded  at  its  cir- 
cumference by  the  shreds  of  the  torn  covering  of  the  vesicle.  Experience 
shows  that  it  is  a  very  bad  sign  if  infants  are  born  with  the  developed  erup- 
tion; they  invariably  die,  sooner  or  later. 

3.  Congenital  enlargement  of  the  spleen  is  always  extremely  suggestive 
of  lues.  It  is  an  easily  established  sign  of  visceral  syphilis  which  the  new- 
born carries  over  from  the  fetal  to  the  postnatal  life.  Of  course,  the 


SYPHILIS  759 

enlargement  is  not  always  clinically  apparent;  very  often  the  organ  is  not 
palpable  below  the  margin  of  the  ribs. 

Splenic  tumor,  however,  is  a  very  constant  occurrence  in  infantile 
syphilis.  Even  though  it  be  absent  during  the  first  few  days  it  will  surely 
develop,  if  but  for  a  short  period.  The  careful  observer  will  hardly  ever 
overlook  it.  True,  the  enlargement  of  the  spleen  is  given  third  place  in  this 
recital  because  it  is  not  as  prominent  a  symptom  as  the  other  two,  which  as 
indicators  par  excellence  immediately  lead  the  physician  in  the  right  direc- 
tion. The  cases  are  very  rare  in  which  a  hard,  easily  palpated  spleen, 
discovered  during  the  first  three  months,  and  that  means  before  the  period 
of  florid  rickets,  signifies  anything  but  syphilis  or  tuberculosis. 

Syphilitic  disease  of  the  liver  hardly  ever  causes  any  distinct  manifes- 
tations in  infancy.  The  liver  of  the  new-born  is  frequently  and  normally 
large  and  therefore  it  is  not  always  easy  to  draw  any  absolute  line  between 
its  physiologic  and  pathologic  conditions.  In  studying  the  status  of  the 
liver  it  is  necessary  to  note  the  factor  of  consistency  as  well  as  that  of  size. 
If,  on  the  other  hand,  the  liver  has  been  the  seat  of  extended  changes  during 
fetal  life,  the  infant  may  be  born  with  a  true  cirrhosis.  In  this  event,  the 
liver  is  very  hard,  friable,  and  usually  markedly  enlarged;  the  abdomen  is 
distended  and  tense  and  a  distinctly  outlined  venous  net-work  is  seen  on  the 
surface.  The  firm  splenic  tumor  is  then  always  present.  Icterus  and  as- 
cites  may  develop,  but  are  usually  absent.  If,  however,  progressive  retrac- 
tion of  the  interstitial  liver  tissue  causes  obstruction  to  the  flow  of  bile,  a 
very  severe  icterus  will,  of  course,  ensue.  This  event  may  determine  the 
entire  disease-picture.  If,  following  the  physiologic  jaundice  of  the  new- 
born, a  high  grade  of  icterus  persists,  the  child  retaining  the  lemon-yellow 
color  for  weeks  or  months,  with  white  acholic  stools  and  dark  brown  urine, 
syphilis  must  always  be  suspected,  provided  that  congenital  malformations 
involving  the  liver  can  be  ruled  out.  In  such  a  case,  strangely  enough,  other 
manifestations  of  lues  may  be  lacking. 

Protein  and  casts  are  frequently  found  in  the  urine  of  syphilitic  children. 
These  findings  are  to  be  regarded  as  evidences  of  specific  injury  to  the  kid- 
neys, since  pathologic  renal  changes  have  been  clearly  demonstrated 
microscopically,  not  alone  in  the  fetus,  but  in  the  infant.  Nevertheless,  it 
is  always  to  be  remembered  that  albuminuria  is  a  symptom  of  all  possible 
sorts  of  disease  among  infants  and  is  especially  common  in  the  course  of 
disturbances  of  nutrition. 

Osteochondritis,  so  extremely  characteristic  of  fetal  lues,  has  been  dis- 
cussed and  will  be  considered  even  more  fully  in  a  later  page.  It 
should  be  said,  only,  that  certain  children  are  born  with  bone  diseases  in 
advanced  stages.  Sometimes  the  joints  are  so  severely  affected  that  they 
cannot  be  moved.  The  limb  lies  entirely  motionless.  If  an  arm  is  involved 
one  may  be  led  at  first  to  suspect  a  birth  paralysis,  thus  putting  the  obste- 
trician under  suspicion  and  often  causing  great  injury  by  the  improper 
treatment  of  the  child.  A  careful  analysis  of  the  local  condition  in  rela- 
tion to  the  general  disease  will  readily  put  one  on  the  right  track. 

Syphilitic  disease  of  the  nervous  system  and  of  the  sense  organs  usually 


760 


TEXT-BOOK  OF  PEDIATRICS 


does  not  appear  until  a  later  period  of  life.  Though  the  disease  does  not 
appear  clinically  at  this  time,  the  infection  of  the  nervous  system  which 
causes  later  symptoms  is  already  present.  Among  the  congenital  affections 
of  the  eye,  however,  primary  plastic  iritis,  with  extensive  posterior  synechia, 
should  be  mentioned,  since  it  represents  a  condition  very  pathognomonic 
of  lues. 

It  is  not  surprising  that  syphilitic  children  are  often,  and  indeed  com- 
monly, below  normal  weight  even  though  born  at  term.  Primarily,  specific 
retardations  of  growth  doubtless  contribute  to  this  result.  In  the  second 
place,  and  probably  of  even  greater  importance,  is  the  interference  with  the 


R. 


FIG.  194. — Congenitally  syphilitic  twins. 


L. 


R.  The  diffuse  infiltration  of  the  skin  is  very  distinct,  especially  on  the  hands,  arms  and 
feet.  Crusty  syphilide  surrounding  the  mouth  and  on  the  chin.  L.  Circumscribed  pustular 
syphilide  in  face,  especially  marked  on  forehead.  Rhagades  of  the  lips  (Children  'a  Hospital, 
Munich,  Prof.  Von  Pfaundler). 

normal  nutritive  interchange  of  the  fetus  with  the  placenta  in  consequence  of 
the  intra-uterine  infection.  With  suitable  care  and  systematic  treatment 
such  children  recover  more  rapidly  than  might  be  expected,  despite  of 
their  congenital  debility. 

In  lues  of  severe  grade,  moreover,  the  conditions  of  intra-uterine  exis- 
tence are  so  poor  that  birth  commonly  occurs  too  early.  What  has  been 
said  of  habitual  abortion  applies  also  to  successive  and  repeated  premature 
births.  They  are  typical,  in  a  degree,  of  syphilis  and  are  almost  always  to 
be  found  in  the  history  of  lues. 

All  the  symptoms  described  are  not  necessarily  present  at  birth.  The 
infant  may  be  born  apparently  healthy  and  one  or  another  sign  may 
appear  distinctly  during  postnatal  life.  Snuffles,  pemphigus,  the  enlarge- 


SYPHILIS 


761 


ment  of  the  spleen  or  liver,  albuminuria,  or  osteochondritis  may  make  their 
appearance  at  any  time,  although  seldom  later  than  the  close  of  the  second 
month  and  usually  during  the  first  few  weeks. 

This  is  particularly  true  of  the  great  group  of  exanthemata  and  other 
skin  manifestations  of  hereditary  and  infantile  syphilis.  Of  this  group  we 
have  mentioned  only  pemphigus  of  the  new-born  because  this  is  so  fre- 
quently present  at  birth  or  makes  its  appearance  during  the  first  few  days 
of  life.  The  eruptions  of  the  other  exanthemata  generally  appear  at  a  later 
period.  Sometimes  these  eruptions  develop  gradually  in  the  course  of 


FIG.  195. — Hereditary  syphilis,  rhagades,  bloody  rhinitis   and  excoriations 
around  mouth  before  treatment. 

other  symptoms,  or  again  they  break  out  suddenly  and  disclose  at  once  the 
whole  dark  disease-picture. 

In  infancy  two  main  groups  of  syphilitic  dermatoses,  broadly  separated 
in  their  clinical  features,  are  recognized : 

1.  The  diffuse  flat  syphilide,  or  the  diffuse  infiltration  of  the  skin. 

2.  The  circumscribed  eruptions,  or  the  syphilitic  exanthemata,  in  the 
narrower  sense  of  the  term. 

1.  The  diffuse  cell  infiltration  has  already  been  described  as  the  most 
important  histologic  sign  of  syphilitic  disease  of  the  congenital  type  in  the 
internal  organs.  The  skin  may  become  diseased,  at  a  later  period,  in  a 
manner  entirely  analogous  to  the  visceral  process.  Deep-seated,  wide- 
spread and  continually  progressive  cell  proliferation  occurs,  which  event- 
ually leads  to  a  diffuse  infiltration  of  the  skin,  recognizable  at  the  first 
glance.  Clinically  this  infiltration  appears  as  a  thickening  and  toughening 


762  TEXT-BOOK  OF  PEDIATRICS 

of  the  skin.  In  extreme  cases  the  normal  elasticity  of  the  cutaneous  tissues 
is  entirely  lost.  Wrinkles  and  fissures  form,  especially  in  parts  where  the 
unyielding  dense  tissue  is  subjected  to  mechanical  force.  Very  often  the 
affected  parts  of  this  skin  are  reddened  and  inflamed.  This  diffuse  infil- 
tration of  the  skin  is  never  present  at  birth,  but  always  develops  at  a  later 


FIG.  196. — Hereditary  syphilis,  rhagades   after   treatment.    Same   case 
as  Fig.  195. 

period.  Nevertheless,  it  is  a  special  peculiarity  of  congenital  syphilis  and 
never  occurs  in  the  acquired  form. 

At  times  the  entire  skin  from  head  to  foot  takes  on  the  characters 
described.  Usually,  however,  certain  parts  only  of  the  skin  are  affected  and 
more  particularly  on  the  face,  the  hands  and  the  feet.  The  trunk  com- 
monly remains  entirely  free. 

Many  of  the  external  signs  of  lues  are  associated  with  this  pathologic 
condition  of  the  skin.  The  peculiar  pallor  of  the  face  of  the  congenitally 
syphilitic  infant  is  one  of  these  and  while  it  is  not  constant,  it  is  still  seen  very 
frequently.  There  has  been  no  lack  of  effort  to  find  a  term  to  fitly  describe 
this  typical  color  of  the  skin,  but  no  better  designation  than  that  of  earthy 
sallowness  or  waxy  pallor  has  been  discovered.  Trousseau  compares  the 
color  to  that  of  weak  coffee  diluted  with  a  large  quantity  of  milk.  After 


SYPHILIS 


763 


the  pallor  has  persisted  for  some  time  and  large  deposits  of  pigment  have 
occurred  he  likens  it  to  the  stains  on  the  fingers  of  the  cigarette  smoker. 
Often  the  pale  red  of  the  lips  of  such  children  offers  so  little  contrast  to  the 
color  of  the  face  that  the  line  of  the  lips  is  not  sharp  and  seems  to  blend 
with  the  surrounding  skin.  In  other  words,  this  pseudoanemia  of  young 
syphilitic  infants  is  not  due  to  a  lack  of  blood-supply,  but  rather  to  the 
thickening  and  increased  tension  of  the  skin  of  the  face. 

The  infiltration  is  especially  marked  around  the  mouth,  nose,  and  eye- 
lids. With  the  frequent  movement  of  these  parts  of  the  skin,  superficial 
and  sometimes  deeper  fissures  are  readily  formed.  This  is  seen  particularly 
in  the  radiating  rhagades  of  the  lips,  an  extremely  important  stigma  of 
the  luetic  facies.  If  the  infiltration  is  distributed  over  the  entire  skin, 
the  face  naturally  takes  on  a  rigid,  mask- 
like  expression. 

Very  frequently  a  scab-like,  dessicating 
eruption  develops  on  the  bases  of  this  diffuse 
infiltration.  This  eruption  shows  a  very  close 
resemblance  to  the  ordinary  impetiginous  ec- 
zema. The  parts  in  which  fissures  readily  oc- 
cur are  especially  predisposed.  Accordingly, 
the  dessicative  eruption  is  found  chiefly  around 
the  mouth,  nose  and  eyebrows,  as  well  as  on 
the  forehead  and  scalp  which  it  sometimes 
covers  like  a  helmet.  The  scabs  are  removed 
very  readily  and  do  not  leave  a  bleeding  sur- 
face. The  bases  thus  exposed  are  but  slightly 
reddened  and  present  a  peculiar  satiny  sheen. 
These  are  all  points  of  importance  in  distin- 
guishing these  eruptions  from  the  impetiginous 
form  of  constitutional  eczema  of  the  face,  which 
usually  makes  its  appearance  at  a  later  period. 

It  is  clear  that  this  process  of  infiltration,  if  it  persists  long  enough, 
will  lead  to  serious  disturbances  of  the  nutrition  of  the  skin.  As  one 
result,  we  frequently  see  that  the  hair  of  the  affected  parts  disappears.  The 
eyebrows  and  eyelashes  fall  out  and  even  at  this  early  date  a  widespread 
alopecia  of  the  scalp  may  appear.  Often  the  hair  falls  out  over  certain 
areas  only;  thus  one-half  of  the  head,  from  the  forehead  to  the  occiput,  looks 
as  though  it  had  been  shaved,  while  the  hair  at  the  back  of  the  head  remains 
intact.  The  area  of  the  bald  spot  is  just  the  opposite  of  that  found  in 
rickitic  children. 

Other  points  of  predilection  for  this  diffuse  infiltration  of  the  skin  are 
those  particular  parts  exposed  to  special  external  irritation.  Thus  it  is 
frequently  found  in  large  areas  over  the  nates,  on  the  flexor  surfaces  of  both 
legs,  and  especially  when  these  parts  are  affected  with  intertrigo.  The 
bright  red,  wet  surfaces  gradually  become  dry  and  ri^id,  have  a  brownish 
color  and  present  a  glistening  appearance. 

Another  favorite  localization  of  the  diffuse  infiltration  upon  the  soles  of 


FIG.  197. — Typical  alopecia  in  a 
four  and  one-half-week-old  syphil- 
itic infant. 


764  TEXT-BOOK  OF  PEDIATRICS 

the  feet  and  the  palms  of  the  hand  is  very  significant.  A  similar  tendency  is 
seen  in  syphilitic  pemphigus  of  the  new-born  and  the  papular  forms  of 
exanthem  appearing  later,  seem  to  have  a  predilection  for  these  areas.  This 
is  also  true  of  the  diffuse  flat  syphilide.  The  cause  of  these  localizations  is 
hard  to  fix.  It  may  be  that  the  early  and  numerous  presence  of  sweat 
glands  in  this  region  plays  an  essential  role  (Hochsinger).  In  any  event,  the 
condition  is  very  clearly  characteristic  of  syphilis.  Sometimes  the  soles  of 
the  feet  are  the  only  parts  on  which  the  diffuse  cutaneous  infiltration  is 
found.  The  experienced  physician  will  never  neglect  the  careful  examina- 
tion of  the  soles  of  the  feet  when  lues  is  suspected. 

The  infiltrated  skin  of  the  soles  is  usually  reddened  or  more  often  livid. 
The  peculiar  sheen  is  especially  typical.  Often  times  the  entire  sole  looks 
as  though  it  had  been  varnished  or  covered  with  shellac.  This  is  some- 
times called  the  shiny  or  varnished  heel.  The  sheen  is  caused  mainly  by 
the  extreme  tenseness  of  the  infiltrated  skin.  It  is  usually  impossible  to 


FIG.  198. — Syphilitic  paronychia  of  hands  and  feet.    Papulo-pustular  syphilide  around  mouth. 
Rhagades  of  lips,  loss  of  hair,  of  eyebrows,  and  shaved  forehead. 

wrinkle  the  skin,  or  if  one  does  succeed  in  this,  the  folds  include  only  the 
superficial  epidermis  which  is  but  loosely  connected  with  the  underlying 
tissue.  For  this  reason  large  pieces  of  the  horny  layer  may  at  times  peel  off. 
Not  infrequently  the  first  efflorescence  of  a  later  exanthem  appears  upon  the 
basis  of  the  infiltration  on  the  soles  of  the  feet. 

The  diffuse  infiltration  of  the  skin  causes  very  typical  manifestations 
on  the  finger  and  toe-nails.  A  cushion-like  inflammatory  swelling  of  the 
bed  of  the  nail  occurs,  resulting  in  deep,  trophic  disturbances  of  the  nail, 
the  syphilitic  paronychia.  The  region  of  the  nail-fold  is  of  a  brownish-red 
color,  is  markedly  thickened,  swollen,  shiny  and  scaly,  and  is  at  times 
covered  with  scabs  and  crusts.  The  nails  themselves  become  soft,  thin,  and 
striped,  or  ridged.  They  are  brittle  and  break  off,  or  they  become  soft  and 
maybe  completely  shed.  In  milder  cases  a  fraying  of  the  free  ends,  as  a 
result  of  which  they  become  of  a  pure  white  color,  is  characteristic. 

2.  The  circumscribed  skin  eruptions  of  congenital  lues  resemble  those  of 
acquired  syphilis.  Unlike  the  diffuse  infiltration  of  the  skin  the)'  are  not 
peculiar  to  infantile  syphilis  alone. 

Syphilitic  pemphigus  has  already  been  discussed.    Attention  has  also 


SYPHILIS 


765 


been  called  to  the  fact  that  this  exanthem  is  not  always  present  at  birth  and 
that  an  essentially  similar  pustular  eruption  may  appear  later,  and  usually 
during  the  first  weeks  of  life.  This  eruption  also  occurs  chiefly  on  the  soles 
of  the  feet  and  the  palms  of  the  hands,  but  may  appear  in  other  parts  of 
the  body.  The  vesicles  are  generally  few  in  number.  In  children  affected 
with  this  late  pemphigus  (Hochsinger),  the  prognosis  is  not  so  unfavorable 
as  it  is  with  those  in  whom  the  vesicles  are  present  at  birth  or  appear 
during  the  first  or  second  day. 

Frequently  the  eruption  has  a  more  papular  character  from  the  begin- 
ning, resembling  the  pustules  of  small-pox.  It  is  then  termed  a  papulo- 
pustular  syphilide.  The  content  of  the  pustule  dries  up,  forming  a  thick 
scab  which  frequently  presents  a  concave,  oyster-shell-like  form,  the  rupial 
syphilide.  More  rarely,  the  pustular  exanthem  appears  by  preference  on 
the  dorsal  surfaces  of  the  hands  and  feet,  where  it  consists  of  small  papules, 


FIG.  199. — Maculopapular  syphilide,  especially  marked  on  the  extremities  and  face. 
(Children's  Hospital,  Heidelberg,  Prof.  Moro.) 

set  closely  together  in  circles.  The  eruption  then  has  a  definite  circinate 
form  which  persists  until  it  becomes  confluent. 

Generally  speaking,  however,  in  infancy  this  syphilitic  exanthem  forms 
the  so-called  maculopapular  syphilide.  It  is  so  described  because  the 
efflorescence  gives,  at  first  sight,  the  impression  of  simple  spots,  but  on 
closer  examination  shows  a  slightly  raised  flat  surface  formed  in  layers. 
These  are  actually  found  to  be  small  infiltrated  areas.  Dermatologically, 
therefore,  this  exanthem  is  not  analogous  to  the  roseola  of  acquired  lues. 
The  latter  does  not  occur  in  congenital  lues  at  all  (Hochsinger) 

The  maculopapular  exanthem  never  appears  immediately  after  birth, 
but  requires  an  incubation  period  of  several  weeks.  It  consists  of  small  flat 
sheets,  varying  in  size  from  one-eighth  to  one-half  inch,  which  are  at  first 
of  bright  red  and  later  change  to  a  yellowish-brown  or  salmon  color.  It  is 
distributed  chiefly  on  the  extremities  and  particularly  on  the  extensor 
surfaces  and  the  sides  of  the  legs,  on  the  soles  of  the  feet  and  the  palms  of 
the  hands,  and  on  the  neck  and  face,  while  the  trunk  is  nearly  always 
remarkably  free  from  the  eruption.  Sometimes  the  crop  is  so  scanty  that 


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much  care  must  be  taken  to  discover  occasional  spots  on  the  soles  of  the  feet, 
the  forehead  or  the  chin.  In  other  cases,  the  entire  body  is  thickly  covered, 
so  that  the  exanthem,  at  first  sight,  reminds  one  of  measles.  In  those  por- 
tions of  the  skin  which  are  irritated,  either  mechanically  or  otherwise, 
especially  around  the  anus,  the  exanthem  spreads  in  all  directions  and  not 
infrequently  takes  on  the  character  of  the  so-called  broad  condylomata. 

Subsequently,  the  surface  of  the  efflorescence  is  either  exfoliated,  leaving 
a  smooth,  glistening,  circular  surface;  or  the  exanthem  is  resorbed  from  the 

centre,  leaving  a  very  characteristic  light 
brown  pigmentation  which  gives  a  mottled 
appearance. 

The  sudden  eruption  of  a  widespread 
maculopapular  syphilide  in  infancy  is  by 
no  means  a  bad  sign.  On  the  contrary, 
this  event  rather  indicates  that  the  organ- 
ism is  in  active  response  or  reaction  to  the 
syphilis  antigens.  In  delicate,  weak  infants, 
in  fact,  the  exanthem  is  very  mild;  and  this 
coincides  fully  with  the  clinical  experience, 
that  infants  with  especially  severe  cutane- 
ous symptoms  show  but  slight  visceral 
changes.  Enlargement  of  the  spleen  and 
the  liver,  on  the  other  hand,  are  most  fre- 
quently found  in  children  whose  skin  is 
spared  the  exanthemata  throughout  the 
disease.  Such  cases  are  not  uncommon. 
Hochsinger  has  called  particular  attention 
to  this  fact  and  has  described  such  cases 
under  the  term  syphilis  congentia  sine 
exanthemata. 

Specific  disease  of  the  mucous  mem- 
branes, in  direct  contrast  to  the  frequency 
of  syphilitic  skin  affections,  of  which  only 
the  more  important  have  been  described,  are  uncommon  in  early  infancy. 
Occasionally,  we  find  large  discrete  placques  on  the  tongue,  lips,  or  soft 
palate.  Hoarseness  and  aphonia,  probably  due  to  an  affection  of  the  mu- 
cous membrane  of  the  larynx,  are  quite  common. 

Syphilitic  diseases  of  the  bones  are  frequent  in  early  childhood.  The 
characteristic  osteochondritis  has  been  mentioned  already  and  its  anatomy 
described  under  fetal  lues.  Milder  degrees  of  osteochondral  inflammation 
hardly  cause  any  clinical  manifestations.  If  the  process  continues  and 
reaches  a  severe  grade  it  will  sooner  or  later  produce  a  very  remarkable 
picture.  As  might  be  anticipated  from  the  nature  of  the  disease,  it  is 
always  localized  first  in  the  epiphysis.  The  lower  epiphysis  of  the  humerus 
and  in  the  knee,  thg  epiphyses  of  the  femur  or  the  tibia  are  chiefly  affected. 
In  some  instances  all  four  of  the  extremities  are  affected.  If,  as  is  very  fre- 
quently the  case",  the  lower  epiphysis  of  the  humerus  is  affected,  the  elbow 


FIG.  200. — Parrot's  pseudoparalysis. 
Typical  position  of  right  arm  and  hand. 
Spindle-form  swelling  in  the  region  of 
the  elbow. 


SYPHILIS 


767 


joint  often  appears  spindle-shaped  and  the  entire  region  is  slightly  reddened 
and  heated.  The  serious  disturbance  of  motion  which  the  entire  arm  suf- 
fers is,  however,  the  most  noticeable  symptom.  It  lies  beside  the  body  in  a 
flaccid  paralysis  and  is  rotated  inwards  with  the  back  of  the  hand  turned 
toward  the  trunk.  If  the  arm  is  lifted  by  the  fingers,  which  remain  movable 


• 


L  _          

FIG.  201. — Hereditary  syphilis.     Epiphysitis  and  periostitis  of  lower 
ends  of  ulna  and  radius. 

throughout,  it  falls  back  upon  the  bed  as  though  lifeless.  This  is  not  true 
paralysis,  however,  as  is  the  plexus  paralysis  due  to  birth  traumata,  to 
which  it  is  closely  related  clinically.  The  nerve  supply  is  perfectly  intact; 
the  paralysis  is  only  apparent.  It  may  be  due  to  various  causes. 

(a)  It  may  be  that  as  a  final  result  of  osteochondral  inflammation,  the 
epiphysis  may  have  separated  from  the  diaphysis,  producing  signs  essen- 
tially the  same  as  those  of  true  fracture. 


768  TEXT-BOOK  OF  PEDIATRICS 

(b)  The  process  does  not  necessarily  go  on  to  actual  separation,  but  the 
inflammation  passes  to  the  periosteum  and  to  the  neighboring  musculature, 
resulting  in  intense  pain,  as  may  be  shown  by  every  attempt  at  motion  or  at 
times  by  even  the  slightest  touch.    The  pain  sufficiently  explains  the  lack  of 
motion  in  the  affected  limb.  Periostitis  and  myositis  also  cause  the  char- 
acteristic spindle-form  swelling  around  the  joint. 

(c)  If  there  is  neither  separation  of  the  epiphysis  nor  severe  pain,  not 
uncommonly  true  in  this  form  of  pseudoparalysis,  there  may  be  an  inflam- 
matory affection  of  the  muscles  alone,  causing  diffuse  swelling,  a  polymyo- 


FIQ.  202. — Hereditary  syphilis.     Osteoperiostitis  of  ulna  resembling 
acute  osteomyelitis.     An  uncommon  lesion. 

sitis  over  the  elbow-joint  which  completely  preventseveryactivemovement. 
The  Roentgenogram  of  osteochondritis  is  often  very  instructive.  A 
widened  irregular,  jagged,  dark  epiphysial  line  giving,  at  times,  a  broken 
epiphysial  outline  is  ssen,  with  a  considerably  lighter  zone  toward  the 
diaphysis,  representingthegranulationtissuefoundinthisarea.  Theossifying 
periostitis  is  marked  by  a  dark  shadow  which  covers  the  shaft  like  a  cloak. 
The  inflammation  of  the  fingers  in  syphilitic  infants — phalangitis  syphilitica 
(Hochsinger),  is  less  clearly  marked,  since  it  always  begins  insidiously,  is 
painless,  and  never  causes  serious  disturbance  of  function.  In  extreme 
degrees  it  is  easily  recognized.  The  affected  phalanx  is  enlarged,  giving  an 
olive-shaped  swelling,  and  the  skin  over  it  is  tense,  shiny  and  red.  The  proc- 
ess usually  develops  in  the  proximal  phalanx,  so  that  the  finger  becomes 


SYPHILIS 


769 


bottle-shaped.    At  times,  the  distal  phalanges  may  also  be  affected.    The 
joints  and  the  soft  tissues  are  always  intact.    The  condition  develops  very 
early,  usually  during  the  first  month  and  is  generally  multiple.     Hardly 
ever  does  it  lead  to  the  formation  of  pus  or 
to  a  fistula.    These  points  are  important  in 
its  differentiation  from  the  tuberculous  spina 
ventosa  which  it  may  closely  resemble  in 
many  other  respects. 

The  central  nervous  system  is  more  fre- 
quently the  seat  of  syphilitic  disease  in  in- 
fancy than  was  formerly  supposed.  The 
brain  and  its  membranes  are  naturally  con- 
sidered first.  Aside  from  the  formation  of 
gummata  and  the  development  of  inflamma- 
tory infiltration  and  sclerosis  which,  begin- 
ning during  fetal  life,  may  lay  the  foundation 
of  later  idiocy,  we  must  first  consider  internal 
hydrocephalus.  The  gradual  appearance  of 
this  condition  must  be  classed  among  the 
common  manifestations  of  congenital  syph- 
ilis. It  is  not  an  early  symptom  and  com- 
monly does  not  occur  until  the  third  or  fourth 
month,  or  even  later.  It  may,  however,  be 
of  congenital  origin  and  it  may  then  reach 
an  extraordinary  size.  The  acquired  form, 
in  contrast  to  the  so-called  rickitic  hydro- 
cephalus, is  comparatively  small.  The  fon- 
tanelle  is  tense  and  bulging.  The  peculiar 
hydrocephalic  stare,  with  inverted  downcast 
eyes,  shown  in  Figure  203,  is  also  present. 
The  head  is  but  slightly  enlarged.  This  may 
be  due,  in  part,  to  the  fact  that  the  cranium 
has  become  rigid  and  unyielding  as  a  result 
of  preceding  or  coincident  inflammatory 
process,  giving  the  type  of  caput  quadratum. 
In  such  cases,  however,  the  pressure  symp- 
toms are  more  marked  and  the  frequent 
appearance  of  convulsions  in  these  infants  is 
easily  explained.  The  convulsions  may  also 
be  explained  by  the  presence  of  an  active 
syphilitic  meningitis.  The  cerebrospinal 
fluid  obtained  by  puncture  is  clear  and  its 
protein  content  is  but  slightly  increased.  The  Wassermann  reaction  on  the 
cerebrospinal  fluid  is  positive  and  the  cells  are  increased,  often  to  four  or 
five  hundred  per  cubic  millimeter,  if  the  meninges  are  actively  involved. 
Inflammatory  diseases  of  the  choroid  plexus  and  of  the  ependyma,  the 
49 


FIG.  203. — Hereditary  syphilis. 
Multiple  bone  and  joint  involvements; 
skull,  left  humerus,  right  tibia  and 
both  elbow  joints.  The  following  four 
illustrations  of  bone  and  joint  lesions 
are  from  this  patient. 


770 


TEXT-BOOK  OF  PEDIATRICS 


primary  disease  of  the  ventricles,  is  probably  the  most  frequent  cause  of 
internal  hydrocephalus. 

In  the  causation  of  the  rarer  external  hydrocephalus,  the  anatomic 
basis  of  which — a  pachymeningitis,  causes  a  collection  of  fluid  between 
the  dura  and  the  pia,  lues  must  be  primarily  considered.  Clinically,  the 


Flo.  204. — Hereditary  syphilis  osteitis  of  skull.     See  Fig.  203. 

condition  is  actually  shown  only  by  the  slightly  sanguineous  spinal  fluid, 
suggestive  of  pachymeningitis  interna.  To  give  proper  valuation  to  this 
discoloration  of  the  cerebrospinal  fluid  one  must  be  able,  of  course,  to  ex- 
clude hemorrhage  due  to  the  puncture  itself. 

Of  the  sense  organs  the  eye  is  most  frequently  affected.  The  plastic 
iritis  of  the  new-born  has  been  mentioned.  At  a  later  period  inflammation 
of  the  retina,  a  syphilitic  retinitis,  is  a  symptom  of  specific  disease  which  the 


SYPHILIS 


771 


ophthalmologists  consider  valuable.  Choroiditis  also  often  develops.  The 
rare  optic  neuritis  of  infantile  syphilis  rapidly  leads  to  total  blindness. 
Parenchymatous  keratitis,  so  common  in  congenital  syphilis  of  tardy  de- 
velopment, is  remarkably  infrequent  in  infancy. 

The  vascular  system  often  shows  marked  venous  ectasia.  This  is  espe- 
cially distinct  in  the  scalp  and  over  the  temporal  region  where  the  course 
of  the  veins  is  sometimes  marked  by  deep  winding  grooves  in  the  bone. 


FIG.  205. — Hereditary  syphilis,  osteitis  of  humerus.     See  Fig.  203. 

Fournier  considers  this  to  be  in  the  nature  of  a  dystrophy.  Hochsinger,  on 
the  other  hand,  attempts  to  find  the  cause  of  the  enlargement  of  the  tem- 
poral veins  in  a  coexisting  hydrocephalus.  It  must  be  remembered,  however, 
that  markedly  ectatic  veins  are  seen  where  there  is  no  hydrocephalus  or 
but  in  very  slight  degree.  They  may  be  found  sometimes  in  other  parts 
of  the  body  and  even  in  the  extremities. 

Syphilitic  endarteritis,  a  very  common  pathologic  finding,  even  in 
infancy  (Heubner),  is  very  seldom  determined  clinically  at  this  early  age. 
This  phase  of  the  disease,  which  affects  chiefly  the  blood-vessels  of  the 


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TEXT-BOOK  OF  PEDIATRICS 


brain,  is  readily  recognized  after  the 
first  years  of  life.  As  a  frequent  cause 
of  encephalitic  processes  it  plays  an  im- 
portant part. 

In  this  disease,  as  in  tuberculosis,  a 
general  swelling  of  the  lymph  nodes,  in 
the  form  of  small,  hard  tumors,  appears. 
The  diagnostic  value  of  this  micro- 
polyadenitis  must,  of  course,  be  very 
carefully  weighed,  since  it  may  be  found, 
also,  in  non-syphilitic  infants  suffering 
with  disturbances  of  nutrition.  The 
frequent  affection  of  the  cubital  nodes, 
while  not  pathognomonic  by  any  means 


FIG.  206. — Hereditary  syphilis,  elbow- joint,  the  "  Whorled" 
appearance  is  characteristic.       Same  patient  as  Fig.  203. 


L... 

FIG.  207. — Hereditary  syphilis  osteoperiosti- 
tis  of  right  tibia.     See  Fig.  203. 


of  lues,  is  important,  for  the  nodes  of  this  region  are  but  rarely  affected  in 
other  conditions. 


SYPHILIS 


773 


Since  syphilis  is  a  chronic  infectious  disease,  it  is  not  surprising  to  find 
occasional  rises  of  temperature  without  apparent  cause.    This  finding  does 
not  necessarily  imply  a  mixed  or  secondary 
infection  or  any  other  complication.    An 
active  syphilis  is  sufficient  cause  in  itself 
for  such  a  reaction.    Of  course,  the  temper- 
ature rise  is  never  very  great  and  is  by  no 
means  characteristic. 

Sooner  or  later  a  high  grade  of  anemia  is 
a  feature  of  the  disease-picture.  This  is 
often  associated  with  considerable  reduction 
of  the  number  of  red  blood-cells  and  a 
marked  diminution  of  their  hemoglobin 
content.  Pathologic  blood  elements  also 
appear  in  the  stained  preparation  from  time 
to  time.  The  lymphocytes,  as  a  rule,  are 
notably  increased.  There  are  periods  in  the 
course  of  the  disease  during  which  the  uni- 
form delicate  pallor  is  very  pronounced, 
when  indeed,  it  presents  the  only  symptom. 
Children  so  anemic  are  very  frail  and  may 
die  suddenly  as  the  result  of  some  slight 
indisposition.  Furthermore,  nearly  all  these 
little  syphilitics  show  an  increased  predis- 
position to  disease  and  to  disturbances  of 


FIG.  208. — Multiple'thickening  of  the 
bones  in  congenital  lues.  (University 
Children's  Hospital,  Breslau,  Prof. 
Tobler.) 

nutrition.  La  grippe,  pneumonia, 
etc.,  usually  affect  them  with 
much  more  than  ordinary  severity. 
This  will  be  readily  understood 
when  it  is  remembered  that  these 
children  have  had  to  fight  a  hard 
fight,  that  they  have  constantly 
fought  under  the  deteriorating  in- 
fluence of  a  powerful  poison,  which 
has  reduced  almost  the  entire  or- 
ganism to  a  condition  of  functional 
debility.  To  this  status  the  terms 
parasyphilis,  syphilitic  deuterop- 
athy,  or  syphilism  have  been  applied  and  we  speak  of  parasyphilitic  anemia, 
parasyphilitic  debility,  etc.  It  might  be  better,  however,  to  reserve  this  con- 


Fio.  209. — Moderate  syphilitic  hydrocephalus,  and 
natiform  head.  One  and  one-half-year-old  girl.  (Uni- 
versity Children's  Hospital,  Zurich,  Prof.  Peer.) 


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ception  for  those  cases  in  which  these  anomalies  appear  as  signs  of  consti- 
tutional degeneration  in  the  non-syphilitic  descendants  of  syphilitic  parents. 

RECURRENCES    IN    EARLY   CHILDHOOD 

From  time  to  time,  manifestations  of  the  disease  appear  suddenly  in 
congenially  syphilitic  children,  after  long  intervals  of  apparent  recovery, 
which  must  be  looked  upon  as  recurrences.  The  manifestations  already 
described  are  in  the  main  merely  individual  symptoms  in  a  continuous 
reaction  process,  the  persistent  and  uninterrupted  course  of  which  is  not 
appreciated  because  of  the  occasional  absence  of  definite  clinical  signs  to 
mark  it  with  unmistakable  clearness.  Naturally  many  of  these  reappearing 
phenomena  suggest  relapse,  since  they  announce  the  reawakening  of  a  proc- 
ess which  often  runs  its  complete  course 
during  fetal  life.  Nevertheless,  their 
recurrent  quality  is  not  so  clear  as  when, 
after  many  months  or  even  years  of 
repair,  fresh  outbreaks  occur  suddenly 
and  show  the  renewed  activity  of  linger- 
ing foci  of  spirochaetes.  In  the  meantime, 
partly  as  the  result  of  a  measure  of  im- 
munity attained  during  the  struggle  of 
these  early  months  and  partly  because 
of  its  more  advanced  development,  the 
organism  has  acquired  a  different  sort  of 
reaction  to  the  syphilitic  poison,  dis- 
tinctly shown  in  the  altered  character  of 
the  clinical  symptoms.  The  evidences 
of  reaction  are  no  longer  of  so  general  a 
nature.  They  are  more  definitely  local- 
ized and  confined  to  special  parts,  where 
they  assume  a  more  intensive  type. 
Very  often  the  course  of  these  reactions 
is  extremely  rapid.  Eruptions  appear  suddenly  and  disappear  as  quickly. 
Accordingly,  they  are  very  amenable  to  local  treatment.  This  is  particularly 
true  of  the  broad  condylomata  of  the  skin  and  of  the  syphilitic  placques  of 
the  mucous  membranes,  both  of  which  are  so  typical  of  this  recurrent  period 
as  to  have  suggested  the  term,  the  condylomatous  stage  (Heubner). 

Externally,  these  condylomata  are  exactly  like  those  of  acquired  lues. 
They  are  red,  exudative,  proliferating  papules,  varying  from  one-eighth  to 
one-half  inch  in  diameter.  They  spread  rapidly  in  all  directions,  often 
showing  irregular  indentations  and  fissures  upon  their  surfaces.  They  are 
found  most  frequently  around  the  anus  and  the  genital  organs,  while  the 
structurally  similar  placques  are  found  on  the  lips,  on  the  upper  surface  of 
the  tongue,  or  on  the  tonsils.  Children  of  two  to  four  years  of  age  are 
commonly  affected. 

Gummatous  neoplasms  are  of  rarer  but  occasional  occurrence  at  this 
period.  They  appear  in  the  skin  and  subcutaneous  tissues  and  especially 


FIG.  210. — -Recent  papules  of  the  labia. 
Wide  condylomata  around  the  anus. 
Recurrence  of  congential  syphilis  in  two  and 
one-half-year-old  child. 


SYPHILIS  775 

on  the  fingers,  feet  and  scalp.  They  develop  as  multiple  nodular  infiltrates. 
If  these  are  not  recognized  and  treated  early  they  break  down  rapidly  and 
leave  sharply  chiselled,  white  ulcers,  with  indurated  bases,  which  prove 
extremely  obstinate.  In  the  larynx  they  occur  in  the  form  of  knotty, 
papular  proliferations  which  sometimes  cause  croupy  symptoms.  In  the 
viscera,  and  especially  in  the  liver,  they  form  the  so-called  solitary  syphilide. 

The  nodular  swellings  of  the  testes  which  are  occasionally  observed  in 
the  course  of  these  relapses  are  not,  as  a  rule,  true  gummata  but  represent  a 
diffuse  interstitial  cell  proliferation. 

General  exanthemata,  resembling  those  of  the  earlier  eruptive  period, 
also  occur.  They  are  comparatively  rare  and  run  a  characteristically 
milder  course. 

Infantile  pseudoleukemic  anemia,  with  its  enormous,  hard  spleen,  is  not 
uncommon  in  syphilitic  children  and  usually  develops  during  the  second 
year.  Severe  rickets  is  commonly  associated  with  it,  but  the  essential  part 
which  syphilis  plays  in  its  causation  cannot  be  determined.  The  possibility, 
however,  must  be  admitted.  The  frequency  with  which  pseudoleukemic 
anemia  occurs  with  rickets  alone/ when  no  syphilis  can  be  demonstrated, 
casts  considerable  doubt  on  syphilis  as  a  factor. 

LATE  CONGENITAL  SYPHILIS 

Congenital  syphilis  may  break  out  anew,  and  in  special  guise,  at  the 
period  of  the  second  dentition,  and  frequently  even  later  during  the  develop- 
ment of  puberty.  While  in  early  childhood  the  condylomata  give  a  char- 
acteristic feature  to  the  relapse,  the  entire  clinical  picture  is  now  governed 
by  the  gummata.  Gummatous  proliferations  are  found  in  the  bones,  the 
periosteum,  and  the  bone-marrow;  gummatous  nodules  in  the  skin  and 
mucous  membranes;  gummata  in  the  brain,  the  liver,  the  spleen  and  the 
lymph  nodes.  None  of  these  processes  are  distinguishable,  either  clinically 
or  anatomically  from  the  tertiary  phenomena  of  acquired  lues. 

Gummata  of  the  bones  are  found  most  commonly  in  the  tibia,  the 
cranium  and  the  sternum.  The  nodules,  primarily  soft,  soon  become  hard, 
and  subsequently  show  a  great  tendency  to  ulceration.  They  may  go  on  to 
deep,  irregular,  and  obstinate  sores.  If  the  nodules  are  resorbed,  per- 
manent scars,  the  so-called  tophi,  firmly  adherent  to  the  skin,  are  left  in 
the  bone.  These  gummata  do  not  arise  from  the  bone  substance  itself, 
but  from  the  periosteum.  In  the  hard  palate  and  in  the  nasal  septum  the 
gumma  is  often  situated  in  the  marrow  and  proliferating  thence  may  finally 
lead  to  deep  erosions  and  complete  perforation,  leaving  cavities  of  variable 
size.  The  saddle  nose  of  syphilitic  children,  however,  usually  dates  back  to 
the  period  of  the  first  eruption. 

Similar  perforations  arise  also  from  the  mucous  membranes.  Not 
infrequently  depressed  radiation  scars  of  the  soft  palate,  the  faucial  pillars 
and  the  uvula  are  seen.  In  the  tonsils,  at  first  swollen,  indurated  and  deeply 
infected,  the  gummatous  process  readily  leads  to  ulcerative  breaking  down 
of  tissue.  The  remnants  present  a  yellowish-white  slimy  mass.  The  inex- 
perienced observer  immediately  thinks  of  diphtheria  and  may  even  resort 


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to  antitoxin.  Of  course,  the  serum  fails  of  result.  Severe  and  readily 
recurring  affections  of  the  mucous  membranes  are  observed,  especially  in 
those  syphilitics  who  in  early  childhood  have  shown  the  distinct  manifesta- 
tions of  exudative  diathesis,  giving  the  so-called  scrofulo-syphilis. 

The  gummata  of  the  skin  are  sometimes  very  large  when  they  arise  from 
the  subcutaneous  cellular  tissue.  They  exhibit  a  course  similar  to  the 
gummata  of  the  earlier  period  of  recurrence  already  described.  Again  they 
may  be  small,  varying  from  the  size  of  a  pinhead  to  that  of  a  pea.  These 
small  nodules  always  lie  very  closely  together,  as  in  lupus;  they  ulcerate 
readily  and  very  frequently  have  a  serpiginous  or  a  circular  arrangement. 

Of  the  viscera,  the  liver  is  most  fre- 
quently affected.  The  large  gumma  of 
this  organ  and  the  hypertrophic  cirrhosis 
frequently  associated  with  it,  develop 
enormous  tumors.  In  such  cases  the 
spleen,  also,  is  always  markedly  enlarged. 
If  ascites  is  added,  the  condition  may 
simulate  tuberculous  peritonitis,  but  the 
confusion  is  cleared  if  jaundice  appears. 
Moreover,  in  these  cases,  other  stigmata 
of  syphilis  can  always  be  found. 

The  rare  circumscribed  gummatous 
formations  in  the  brain  result  in  intense 
headache,  occurring  chiefly  at  night,  and 
lead  on  to  epileptic  attacks  and  paralyses. 
True  gummata  of  the  lymph  nodes  appear 
in  the  very  slow  but  noticeable  intumes- 
cence of  isolated  groups,  especially  in  the 
neck.  The  common  enlargement  of  the 
cubital  nodes,  usually  presents,  patholog- 
ically, only  a  simple  hypertrophy. 

The    hyperplastic    periostitis    of   the 
FIG.  211.—  Periostitic  thickening  of  both     diaphysis  of  the  tibia  is  a  frequent,  a 

tibia,  especially  marked  on  right,  case  of  .      -.  ,  .  , 

late  congenital  syphilis,  six-year-old  girl,     very  typical,  and  a  quite  pathognomonic 

symptom  of  this  period.     The  overlying 

skin  is  thickened,  tense,  shiny  and  slightly  reddened.  Usually  the  con- 
dition is  attributed  to  a  trauma  which  has  occurred  at  some  previous 
date  and  which  may  enter  into  the  consideration  as  a  causative  factor. 
Upon  palpation,  which  may  or  may  not  be  painful,  one  gets  the  impression 
of  a  solid  spindle-shaped  tumor.  Often  times  an  irregular  outline  due  to 
small  excavations  makes  the  sharp  edge  of  the  tibia  feel  like  a  blunt  saw. 
At  times  the  edge  cannot  be  felt  at  all,  being  completely  rounded  off. 

The  disease  affects  mainly  the  periosteum  which  gradually  ossifies  and 
repeatedly  forms  a  new  shell  around  the  bone.  In  advanced  cases  the  tibia 
may  become  curved,  the  curve  characteristically  taking  a  forward  direction 
and  resulting  in  the  well-known  saber  tibia — a  beautiful  subject  for  radio- 
graphic  demonstration. 


SYPHILIS 


777 


At  this  period,  a  very  important,  although  not  an  absolutely  pathogno- 
monic  sign  of  late  syphilis  appears  in  the  form  of  a  parenchymatous  kerati- 
tis.  This  lesion  sometimes  leaves  a  permanent  clouding  of  the  cornea, 
which  serves  as  an  important  stigma.  Manifestations  of  late  syphilis  in  the 
internal  ear  almost  always  cause  complete  deafness. 

Keratitis  and  deafness  not  infrequently  occur  together.  To  these  may 
be  added  a  third  external  sign  affecting  the  incisors.  This  completes  the 
Hutchinson  's  triad,  so-named  from  its  original  demonstrator. 

This  physician  also  described  the  anomalies  of  the  teeth  very  accurately 
and,  as  a  result,  they  are  known  as  "  Hutchinson's  teeth. "  The  cutting  edges 
of  the  upper  central  incisors  are  concave  and  their  lateral  edges  are  rounded 


FIG.  212. — Hutchinson's  teeth  and  microdontia  in  late 
congenital  luea.     Ten-year-old  girl. 

or  convex.  Frequently,  but  not  invariably,  the  dentine  is  exposed  at  the 
base  of  the  concave  edges  as  a  result  of  enamel  defect. 

According  to  Heubner,  another  symptom  may  form  the  fourth  member 
of  this  group  in  the  form  of  a  chronic,  bilateral,  ankylosing  inflammation  of 
the  knee-joint,  as  a  result  of  a  syphilitic  gonitis.  This  begins  as  a  simple 
effusion  into  the  joint  cavity  and  gradually  extends  to  the  neighboring  bone 
causing  a  permanent  deformity. 

Regarding  progressive  infantile  paralysis  and  infantile  tabes,  both  of 
which  may  be  quite  apparent  even  before  puberty,  the  reader  is  referred  to 
the  chapters  on  Nervous  Diseases. 

THE  DIAGNOSIS  OF  CONGENITAL  SYPHILIS 

Not  much  can  be  added  upon  this  question,  since  the  chief  diagnostic 
points  may  be  deduced  from  what  has  been  said.  For  the  rest,  there  is  no 


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field  in  clinical  medicine  in  which  we  must  depend  so  much  upon  the  teach- 
ings of  practical  experience  and  personal  observation  as  in  this  particular 
domain.  Descriptions,  although  repeatedly  studied,  are  of  little  value. 
Unless  the  physician  learns  to  observe  and  to  study  the  conditions  for 
himself  he  may  never  become  an  adept  in  the  diagnosis  of  syphilis  and  he 
may  inflict  much  injury,  as  he  does,  for  instance,  in  placing  a  syphilitic 
child  with  a  healthy  wet-nurse.  Three  points  may  be  especially  emphasized. 
1.  The  Very  Rare  Occurrence  of  Single  and  Very  Discrete  Clinical  Man- 
ifestations.— Itmust  not  be  imagined  that  the  entire  list  of  signs  and  symp- 
toms described  appears  in  any  one  case.  In  the  infant,  during  the  first  few 
weeks,  the  snuffles,  or  a  palpable  spleen,  or  a  waxy  pallor  of  the  face, with  a 
few  small  fissures  around  the  mouth,  or  a  small  suspicious-looking  spot  on 


FIQ.  213. — Saddle  nose  in  congenital  syphilis.    (Children  "s 
Hospital,  Munich,  Prof.  Pfaundler.) 

the  forehead,  or  a  peculiarly  shiny  heel  are  not  infrequently  the  only  signs 
discoverable  upon  examination.  By  careful  observation  of  the  course  of 
the  disease  it  is  usually  possible  to  discover  other  signs  from  time  to  time. 

In  very  rare  cases,  however,  early  syphilis  takes  its  course  even  more 
uneventfully.  If  this  were  not  the  case  it  would  hardly  be  possible  to  find 
experienced  men  who  still  believe  in  "syphilis  hereditaria  tarda  sensu 
strictiori, "  in  which  congenital  lues  is  supposed  to  become  manifest  for  the 
very  first  time  in  advanced  childhood,  or  even  later. 

2.  Syphilitic  Stigmata. — These  consist  chiefly  in  scars  left  by  passing 
specific  processes  and  in  permanent  changes  in  the  skeleton.  It  may  readily 
be  imagined  that  the  discovery  of  such  stigmata  often  decides  at  once  the 
nature  of  a  cerebral  disturbance  or  a  chronic  pelvic  condition.  Besides  the 
less  common  formation  of  scars  in  the  mouth  and  the  throat  and  around  the 
anus,  often  indistinct  radial  scars  at  the  edges  of  the  lips  are  an  undeniable 


SYPHILIS 


779 


sign  of  congenital  lues  (Hochsinger) .  In  the  osseous  system,  the  saddle 
nose  must  be  considered  a  most  important  stigma,  especially  when  it  is 
combined  with  a  hydrocephalic  cranium,  and  a  protruding  forehead  and 
occiput — the  caput  quadratum. 

We  must  be  warned,  however,  against  laying  too  great  stress  upon  the 
diagnostic  value  of  a  "pug  nose. "  In  such  a  case,  the  form  of  the  noses  of 
the  parents  must  be  taken  into  consideration  in  order  to  determine  whether 
it  is  not  a  question  of  an  ordinary  familial  peculiarity.  In  early  infancy,  in 
fact,  a  "pug  nose"  is  a  very  common  thing.  The  presence  of  Hutchinson's 
teeth  alone  is  not  a  very  definite  sign. 

While  children  with  congenital  syphilis  are  often  small  and  of  poor  sexual 
development  (infantilism),  this  is  not  necessarily  true. 

3.  Suspicious  Signs  in  Non-syphilitic  Children  or  Symptoms  of  Pseudo- 
lues. — The  beginner  often  makes  the  diagnosis  of  syphilis  upon  the  strength 


FIG.  214. — Plaques  erosives  (syphilitic  erythema  of  the  nates).     (Dresden  Infants  Institute, 

Prof.  Schlossmann.) 

of  changes  which  have  no  real  relation  to  lues.  Especially  misleading  in 
this  respect  are  the  so-called  placques  erosives,  which  very  often  occur  in 
areas  of  improperly  treated  intertrigo  or  in  the  course  of  a  papulo-vesicular 
dermatitis  of  the  nates.  Decubitus  of  the  heel  in  atrophic  infants  also  causes 
mistake.  More  pardonable  is  the  confusion  of  certain  cases  of  dermatitis 
exfoliativa  with  syphilis,  especially  when  the  region  of  the  mouth  is  infil- 
trated and  covered  with  excoriations  and  fissures  (see  Fig.  195).  On  the 
contrary,  erythrodermia,  with  its  general  seborrhcea,  is  easily  distinguished. 
The  snoring  respiration  of  infants  with  adenoids  may  possibly  resemble,  in  a 
degree,  the  snuffles  of  the  luetic.  Bednar's  aphthae  and  thrush  have  no 
more  relation  to  lues  than  has  the  geographical  tongue.  It  is  not  impos- 
sible, however,  that  a  very  distinct  geographical  tongue  may  develop  as  a 
late  result  of  a  syphilo-toxic  dyscrasia. 

The  Wassermann  reaction  is  a  great  aid  in  the  determination  of  a  dif- 


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ferential  diagnosis.  This  reaction  depends  upon  the  presence  of  a  thermo- 
stabile  body  in  the  blood-serum  of  the  syphilitic  individual,  which  possesses 
great  affinity  for  lipoid  organic  substances  soluble  in  alcohol.  The  original 
method  of  Wassermann  has  so  far  proved  most  reliable.  By  this  method 
the  inactivated  serum  to  be  examined  is  mixed  with  a  watery  extract  of  the 
liver  of  syphilitic  fetuses.  If  the  serum  of  guinea  pigs,  containing  comple- 
ment, is  added  to  this  mixture,  the  complement  is  combined  if  the  serum,  to 
be  tested  is  luetic.  This  combination  of  the  complement  does  not  permit  any 
further  action.  If  now  a  so-called  hemolytic  system  (e.  g.,  blood-cells  of  a 
sheep  inactivated  anti-sheep's  blood  immune  serum  from  the  rabbit),  is 
added,  no  hemolysis  or  very  incomplete  hemolysis  of  the  sheep  corpuscles 


FIG.  215. — Luetic  facies  of  a  two  and  one-half-year-old  child. 
Typical  saddle  nose,  moderate  hydrocephalus. 

takes  place;  whereas,  if  the  complement  had  remained  entirely  free  the 
erythrocytes  would  have  been  entirely  dissolved.  The  resulting  limitation 
of  the  hemolysis,  or  its  absence,  serves  as  the  indicator. 

For  the  principles,  the  technic,  and  the  details  of  the  reaction  the  reader 
is  referred  to  special  works  on  serology.  If  it  is  carried  out  by  an  experi- 
enced technician  this  method  is  simple  and  reliable. 

The  original  method  of  Wassermann  has  been  modified  by  most  labor- 
atory workers  by  the  use  of  extracts  of  beef  or  guinea  pig  heart  instead  of 
syphilitic  liver  as  antigen  and  by  using  smaller  amounts  of  reagents.  The 
reaction  is  non-specific  and  is  just  as  reliable  with  non-syphilitic  as  with 
syphilitic  antigen.  The  chief  advantage  of  the  modification  is  the  avail- 
ability of  non-syphilitic  antigen. 

A  distinctly  positive  reaction  is  conclusive,  but  a  negative  reaction  does 
not  absolutely  exclude  lues.  Nevertheless,  the  reaction  is  extremely  useful 


SYPHILIS  781 

in  practice  and  particularly  in  the  recognition  of  occult  cases  of  congenital 
late  syphilis. 

The  demonstration  of  the  spirochaetes,  which  are  readily  found  in  the 
eruption  of  infantile  lues,  is  hardly  necessary  for  a  clinical  diagnosis. 

PROGNOSIS 

The  prognosis  is  dependent  upon  four  main  factors : 

1.  The  Care  and  Feeding. — With  proper  care  and  natural  feeding  the 
prospects  are  generally  good.    With  inefficient  care  and  artificial  feeding, 
on  the  contrary,  they  are  bad.  In  the  mere  matter  of  artificial  food,  however, 
it  is  not  safe  to  say  that  non-syphilitic  children  have  much  advantage  over 
the  syphilitic.    Nevertheless  the  syphilitic  infant  is  usually  weakened  from 
the  start,  and,  therefore,  shows  less  resistance  to  the  innumerable  abuses 
of  feeding  and  care.    To  these  dangers  must  be  added  the  greater  one  of 
secondary  infection  through  numerous  wounds,  rhagades  and  fissures.    But 
even  under  the  most  exemplary  care  the  syphilitic  child  fares  better  with 
natural  than  with  artificial  feeding,  be  the  latter  ever  so  exactly  and  so 
scientifically  conducted. 

2.  The  General  Condition. — 'Weak  syphilitic  prematures  generally  have 
a  poorer  prognosis  than  stronger  full-term  luetics.    This  is  quite  self-evident. 
In  both  cases  the  prognosis  becomes  more  grave  when  some  severe  disturb- 
ance of  nutrition,  or  an  attack  of  la  grippe  or  pneumonia  is  added. 

3.  The  Character  of  the  Syphilis. — Actually,  the  prognosis  depends  to  a 
great  extent  upon  the  character  of  the  syphilis  of  the  parents.    The  pros- 
pects are  much  worse  with  recent  syphilis  than  with  old  infections  and  also 
more  serious  in  untreated  than  in  treated  cases.    The  well  established  fact 
that  the  number  of  still-births  and  premature  births  is  in  a  general  way  pro- 
portionate to  the  age  of  the  parental  syphilis  (Kassowitz),  bears  out  these 
conclusions.    With  regard  to  the  nature  of  the  infantile  syphilis,  there  can 
be  no  doubt  that  the  prognosis  is  more  favorable  if  the  first  signs  of  eruption 
appear  late.    Children  who  are  born  with  distinct  symptoms  almost  always 
succumb.    The  seriousness  of  pemphigus  in  the  new-born  has  already  been 
emphasized.    Similarly,  children  with  marked  visceral  syphilis,  in  whom  no 
distinct  eruption  ever  occurs,  hardly  ever  reach  advanced  childhood. 

4.  Finally  the  prognosis  depends  upon  the  period  at  which  treatment  is 
instituted.    The  earlier  the  specific  treatment  is  begun  the  better  is  the 
prognosis  with  regard,  not  only  to  life,  but  also  to  recovery.    Cases  in 
which  the  treatment  is  begun  at  the  proper  time  and  is  continued  for  a 
sufficiently  long  period  may  never  have  any  recurrences.    Exceptions  to 
this  rule  are  to  be  noted  however. 

The  condylomatous  stage  of  recurrence  in  early  childhood  is  generally 
benign  if  it  is  properly  treated.  This  is  not  true,  however,  of  late  syphilis, 
which  is  extremely  obstinate.  Of  course  the  prognosis  depends  largely  upon 
the  organs  affected.  Disease  of  the  skin  or  the  bones  will  cause  less  anxiety 
than  that  of  the  brain,  liver  or  kidney. 


782  TEXT-BOOK  OF  PEDIATRICS 

THE  TREATMENT  OF  CONGENITAL  SYPHILIS 

Before  entering  upon  the  medicinal  treatment  of  syphilis  two  points  of 
great  importance  must  be  discussed : 

1.  The  prophylactic  treatment  of  the  parents;  2.  The  question 
of  feeding. 

1.  The  tragedy  of  repeated  still  births  and  the  occurrence  of  very  severe 
cases  of  syphilis  of  the  new-born  are  associated  with  untreated  or  but  slightly 
treated  parental  disease.    After  a  recent  and  thorough  course  of  mercury  the 
conditions  are  markedly  improved.    Undoubtedly  it  is  possible  that  a  father 
with  recent  and  untreated  syphilis  can  beget  non-syphilitic  children,  but  this 
is  so  rare  an  exception  that  it  has  small  significance.  A  physician  cannot  give 
his  consent  to  the  marriage  of  the  syphilitic  unless  the  infection  of  the  man, 
probably  the  most  frequent  question  under  consideration,  is  at  least  four 
years  old,  unless  the  patient  has  undergone  several  systematic  courses  of 
treatment,  and  has  shown  no  relapses  during  the  entire  period.     Shortly 
before  marriage  another  course  of  treatment  with  mercury  or  salvarsan 
should  be  instituted.    Even  then  the  advisor  cannot  promise  full  immunity. 
If  the  offspring  of  such  a  marriage  is  infected  an  energetic  course  of  specific 
treatment  should  be  advised  for  both  parents  in  order  to  avoid  infection  in 
future  offspring.    The  mother  should  be  treated  even  though  she  be  preg- 
nant and  without  considering  whether  she  has  or  has  not  shown  symptoms. 

2.  We  have  already  recommended  natural  feeding  for  syphilitic  infants. 
This  presents  no  difficulties  if  the  mother  can  nurse  the  child.    She  cannot  be 
infected  by  her  own  child,  since  she  is  already  infected.    If,  however,  the 
mothercannot  nurse  the  child  for  one  reason  oranother,the  question  of  a  suit- 
able wet-nurse  arises  and  only  a  syphilitic  wet-nurse  can  serve  a  manifestly 
syphilitic  child.  Aside  from  the  obvious  unpleasantness  of  employing  such 
a  person,  it  is  not  always  possible  to  find  her.  The  employment  of  a  healthy 
wet-nurse  for  a  syphilitic  child  cannot  be  considered  and  must  be  absolutely 
prohibited.    It  should  be  forbidden  even  when  a  nurse,  with  full  knowledge 
of  the  circumstances,  is  to  be  hired,  with  the  intention  of  keeping  her  own 
child  at  the  breast  to  prevent  the  loss  of  her  milk  and  of  feeding  the  syphi- 
litic child  the  expressed  milk  only.  Aside  from  the  danger  of  infection  to  the 
nurse,  her  child,  also,  would  be  exposed.    Such  an  arrangement  can  be  made 
without  objection  only  in  institutions.    The  use  of  mother's  milk  obtained 
away  from  the  home,  with  complementary  feeding  later,  is  another  possible 
solution.    If  this  is  impossible,  there  is  nothing  for  it  but  to  fall  back  upon 
artificial  feeding. 

If  the  child  is  entirely  without  symptoms  and  it  remains  so  for  the  first 
four  to  six  weeks  it  may  be  given  to  a  wet-nurse.  But  at  the  slightest  sign  of 
infection  in  the  infant,  under  the  most  careful  observation,  it  must  be 
taken  away. 

Mercury  and  iodides  play  the  leading  role  in  the  therapy  of  syphilis  in 
children.  Numerous  observations  of  the  treatment  with  salvarsan  are 
reported,  but  the  experiences  with  it  in  young  children  and  especially  in 
infants  have  led  to  no  definite  conclusions.  In  older  children  the  results 


SYPHILIS  783 

seem  to  be  about  the  same  as  those  obtained  in  adults.  The  views  of  the 
effects  of  salvarsan'in  infants  are  widely  divergent.  Intramuscular  or  sub- 
cutaneous injection  is  out  of  the  question  on  account  of  the  danger  of  local 
irritation.  Intravenous  injection,  on  the  other  hand,  always  meets  with 
serious  technical  difficulties,  whether  the  injection  be  made  into  the  pre- 
pared vein  of  the  arm  or  into  a  vein  of  the  scalp.  It  is  the  editor's  opinion 
that  arsphenamin  products  have  the  same  usefulness  in  infancy  as  in  later 
childhood  or  in  adults  with  acquired  syphilis,  and  that  for  one  with  ordinary 
skill  serious  technical  difficulties  in  the  intravenous  administration  are 
seldom  encountered.  In  the  majority  of  instances  the  external  jugular  vein 
is  readily  available  without  preparation.  Though  the  longitudinal  sinus  is 
easily  accessible  it  is  recommended  that  it  be  not  used  for  administration  of 
arsphenamin  because  of  the  serious  result  attendant  upon  extravenous 
administration  of  even  minute  amounts. 

With  the  small  doses  employed  in  infants,  there  is  no  essential  dif- 
ference between  salvarsan  and  neosalvarsan.  It  is  the  editor's  opinion 
that  there  is  the  same  difference  as  with  the  large  doses  employed  in  adults. 
As  a  matter  of  fact,  the  dose  is  relatively  as  large  as  in  adults,  viz.,  0.01 
gram  arsphenamin  or  0.015  gram  neoarsphenamin  per  kilogram  of  body- 
weight.  When  treatment  is  first  started  it  is  advisable  to  use  somewhat 
smaller  doses  and  to  proceed  cautiously,  but  later  the  full  dose  stated  above 
may  be  used  with  safety.  A  safe  and  effective  method  is  administration 
every  five  to  seven  days  for  three  doses,  and  a  repetition  of  the  three  doses 
every  two  to  three  months.  For  practical  purposes,  however,  neosalvarsan 
is  probably  to  be  preferred  on  account  of  its  simpler  technic  and 
readier  solubility.  The  salvarsan  treatment,  even  in  infants,  should 
be  combined  with  mercurial  treatment.  Mercury  is  employed  in  two  ways 
in  infancy: 

(1)  By  mouth,  in  powder  form;  and  (2),  by  inunction  in  the  form  of  oint- 
ment. With  young  infants  the  first  method  will  be  found  sufficient. 
Among  the  preparations  which  may  be  given  in  this  way  the  yellow  iodide 
of  mercury  (hydrargyrum  iodatum  flavum),  the  so-called  protoiodide, 
deserves  first  mention.  It  is  given  in  doses  of  0.01  gm.  (gr.  %),  each  day 
and,  if  possible,  is  continued  until  all  symptoms  of  syphilis  have  disap- 
peared. The  treatment  may  be  continued  for  a  subsequent  fourteen  days 
if  desired.  It  is  unfortunate  that  so  many  otherwise  excellent  syphilo- 
graphers  practice  and  teach  the  treatment  of  infantile  syphilis  only  until 
the  disappearance  of  symptoms.  The  same  reasons  for  continued  treatment 
apply  here  as  in  the  case  of  the  adult  with  early  acquired  syphilis.  The 
goal  should  be  the  complete  eradication  of  the  infection  resulting  in  freedom 
from  the  later  manifestations  of  the  disease.  In  some  instances  diarrhoea 
appears  during  the  administration  of  the  protoiodide  of  mercury  and  prob- 
ably as  its  result.  But  these  intestinal  disturbances  are  usually  more 
pleasant  than  the  annoying  eczema  which  may  appear  as  the  result  of  the 
more  difficult  mercurial  inunction  in  the  delicate  skin. 

The  inunction  treatment  is  usually  employed  with  older  children.  It 
does  not  make  much  difference  what  form  of  mercurial  ointment  is  employed. 


784  TEXT-BOOK  OF  PEDIATRICS 

The  important  thing  is  that  one  gram  of  the  ointment  be  gently  but  thor- 
oughly rubbed  for  five  minutes  into  the  skin,  previously  washed  well  with 
soap  and  water. 

In  order  to  protect  the  skin,  the  inunction  is  made  over  a  different  part 
each  time;  for  instance,  the  first  day,  on  the  chest;  the  second  day,  over  the 
abdomen;  the  third  day,  on  the  upper  part  of  the  back;  the  fourth  day,  to 
the  lower  part  of  the  back;  the  fifth  day,  to  the  thigh;  and  the  sixth  day,  on 
the  upper  arm.  This  rotation  is  interrupted  on  the  seventh  day  for  a 
cleansing  bath  and  the  whole  process  is  repeated  several  times. 

If  there  are  deep-seated  local  processes,  such  as  a  tibial  periosteitis, 
local  inunctions  may  be  made  over  it. 

Condylomata  disappear  most  rapidly  with  these  inunctions,  although  the 
same  results  may  be  obtained  by  powdering  the  growths  with  calomel  daily. 

For  the  local  treatment  of  an  obstinate  rhinitis  an  ointment  of  yellow 
mercuric  oxide  or  of  sozoiodolate  of  mercury  (3/2-1  per  cent.),  may  be  intro- 
duced into  the  nose  on  small  cotton  tampons. 

Rhagades  and  other  excoriations  may  be  touched  with  silver  nitrate 
stick  or  in  any  other  appropriate  manner.  They  should  never  be  ignored. 

In  the  manifestations  of  late  syphilis,  the  iodides  are  used  to  great 
advantage  in  combination  with  the  mercury.  The  editor  knows  no  valid  rea- 
son for  not  administering  the  two  drugs  during  the  same  period  if  it  is 
desired.  Either  potassium  or  sodium  iodide  in  aqueous  solution  may  be  used, 
giving  one  teaspoonful  to  one  dessertspoonful  of  a  5  per  cent,  solution  three 
times  a  day  according  to  the  age  of  the  child.  In  order  to  get  efficient  results, 
the  iodide  must  be  continued  for  several  months.  Springs,  the  out  put  of  which 
contains  iodides,  such  as  are  found  at  Talz,  in  Bavaria,  and  at  Halle,  in 
Austria,  are  appropriate  substitutes.  When,  either  by  clinical  observation  or 
by  examination  of  the  cerebrospinal  fluid,  the  central  nervous  system  is  known 
to  be  involved,  it  is  found  that  in  most  early  cases  and  in  many  late  cases 
the  general  systemic  treatment  as  outlined  above  is  effectual  in  accom- 
plishing at  least  a  serologic  cure  and  frequently  a  clinical  cure.  There  can 
be  no  replacement  of  destroyed  nervous  tissue.  If,  after  six  months  to  a 
year  of  such  treatment,  no  improvement  is  noted  either  in  the  clinical 
manifestations  or  the  pathology  of  the  cerebrospinal  fluid,  it  then  becomes 
desirable  to  administer  treatment  intraspinally.  Though  the  value  of 
intraspinal  therapy  is  in  dispute  the  weight  of  evidence  is  in  favor  of  the 
usefulness  of  this  measure.  Our  personal  experience  would  also  bear  this 
out.  The  injection  of  either  neoarsphenamin  or  arsphenamin  in  aqueous 
solution  directly  into  the  subarachnoid  space  has  been  shown  to  be  dang- 
erous because  of  the  irritant  effects.  Serum  arsphenaminized  either  in 
vitro  or  in  vivo  is  much  less  irritant  and  quite  safe  in  proper  dosage.  Serum 
obtained  from  blood  withdrawn  one  hour  after  intravenous  arsphenamin 
contains  in  the  neighborhood  of  0.015  mg.  of  arsphenamin  per  cubic  centi- 
meter. The  amount  of  serum  injected  varies  from  5  to  15  c.c.  according  to 
the  size  of  the  child.  Inactivation  of  the  serum  at  56°  C.  for  one-half  hour 
increases  its  efficacy.  Because  of  the  variability  of  the  amount  of  arsphe- 
namin to  be  found  in  serum  arsphenaminized  in  vivo  a  more  constant  dosage 


SYPHILIS  785 

is  obtained  by  adding  the  arsphenamin  in  vitro  before  inactivation.  The 
dose  should  be  no  greater  than  that  noted  above  and  care  must  be  taken  not 
to  over-alkalinize.  The  intraspinous  treatments  are  more  effective  when 
combined  with  intravenous.  They  may  be  repeated  every  five  to  ten  days 
depending  upon  the  amount  of  reaction  from  the  treatment.  Three  to 
five  such  injections  may  be  made  to  a  series. 

Before  declaring  a  patient  as  possibly  cured  Fournier  required  a  mini- 
mum of  three  to  four  years  of  treatment  and  a  period  of  absence  of  symptoms 
for  eighteen  months  to  two  years.  Modern  arsenical  treatment  has  per- 
mitted the  shortening  of  the  treatment  period.  It  is  also  recognized  that  an 
infection  treated  early  is  more  quickly  eradicated  than  one  treated  late, 
so  that  much  depends  upon  the  stage  of  the  disease.  Even  with  our  more 
modern  methods  it  is  scarcely  safe  to  treat  an  infant  less  than  one  year  or  an 
older  child  less  than  two  years  regardless  of  the  effect  treatment  has  had 
upon  the  Wassermann  reaction.  If  either  the  blood  or  cerebrospinal  fluid 
Wassermann  is  positive  after  this,  time  treatment  must  be  continued  until 
both  are  negative.  Observations  should  then  be  made  at  intervals  for 
several  years  both  in  regard  to  the  Wassermann  reaction  and  recurrence  of 
clinical  manifestations.  Should  there  be  a  recurrence  the  treatment  should 
be  undertaken  as  if  none  had  ever  been  given.  To  the  present  our  experi- 
ence has  been  that  once  a  cerebrospinal  fluid  is  negative  it  always  remains 
negative.  When  a  spinal  fluid  is  once  known  to  be  negative  lumbar  punc- 
ture need  be  made  again  only  for  final  discharge.  Amounts  of  spinal  fluid 
up  to  2  c.c.  should  be  used  for  the  Wassermann  reaction  and  in  addition 
there  should  exist  no  other  pathology  such  as  positive  colloidal  gold, 
globulin  or  increased  cells.  When  determining  the  status  of  the  infection 
by  means  of  the  Wassermann  reaction  all  treatment  should  be  discontinued 
for  at  least  two  weeks  prior  to  taking  the  blood  specimen. 

It  is  the  common  impression  that  hereditary  syphilis  is  cured  with 
difficulty  or  not  at  all.  There  may  be  some  question  as  to  the  absolute  cure 
of  the  disease,  but  with  the  modern  methods  of  treatment  a  persistently 
negative  Wassermann  reaction  and  freedom  from  symptoms  has  been  the 
rule  in  our  hands.  In  some  cases  as  much  as  three  years  of  treatment 
may  be  required.  Sight  is  not  restored  to  a  child  with  optic  atrophy  nor 
does  power  always  return  to  paralyzed  muscles  but  except  for  any  such  irre- 
parable damage  it  is  our  belief  that  every  child  with  hereditary  syphilis 
may  be  cured  as  judged  by  our  present  standards  of  cure. 

II.  ACQUIRED  SYPHILIS  IN  CHILDREN 

Syphilis  may  be  acquired  in  numerous  ways  in  childhood.  The  infection 
may  be  transmitted  during  the  act  of  suckling  of  the  syphilitic  mother  or 
wet-nurse;  or  by  means  of  utensils;  by  caresses,  by  venereal  attendants, 
etc.  Consequently,  the  most  common  location  of  the  primary  lesion  in 
children  is  the  mouth  and  especially  the  lower  lip. 

Otherwise  than  in  the  mode  of  infection,  acquired  syphilis  in  the  child 
presents  the  same  course  as  in  the  adult.  Primary  lesion  and  bubo;  second- 
50 


786  TEXT-BOOK  OF  PEDIATRICS 

ary  stage  with  exanthem  and  condylomata;  and  tertiary  stage  with  the 
symptoms  of  gumma  formation  are  alike. 

The  question  may  arise  frequently,  whether  in  a  given  case  we  have  to 
deal  with  congenital  or  acquired  syphilis,  especially  since  very  mild  initial 
manifestations  may  be  entirely  overlooked  in  the  infant.  In  a  three-year-old 
child,  for  example,  with  several  condylomata  around  the  anus,  the  question 
is  not  always  readily  answered;  for  in  such  a  case  we  may  have  to  deal  with 
a  recurrence  of  congenital  syphilis  or  with  the  secondary  stage  of  an  acquired 
lues.  Similar  difficulties  are  presented  in  the  determination  of  the  manifesta- 
tions of  the  tertiary  stage.  Such  questions  must  not  be  regarded  as  mere 
clinical  subtilties,  for  they  are  certainly  of  practical  importance.  In  the 
first  place,  it  can  hardly  be  a  matter  of  indifference  with  the  father,  whose 
conscience  is  not  quite  clear  upon  questions  of  the  past,  to  know  whether  he 
is  to  blame  for  the  unfortunate  condition  of  his  child  or  whether  the  infec- 
tion has  come  to  the  child  from  an  attendant.  In  the  second  place,  if 
acquired  syphilis  is  proved,  every  effort  must  be  made  to  discover  the 
source,  in  order  to  avoid  further  accidents.  In  such  cases,  the  stigmata, 
described  on  page  778,  are  of  great  value  and  the  most  important  among 
them  are  the  radial  linear  scars  of  the  lips  which  indicate  beyond  doubt 
congenital  syphilis  (Hochsinger).  If,  however,  no  stigmata  whatever  are  to 
be  found  in  a  strong  healthy-looking,  but  infected  child,  acquired  lues  must 
be  considered. 

It  must  be  noted  that  the  general  exanthemata  of  acquired  syphilis  are 
always  of  a  more  spotted  character  and  are  not  maculopapular  as  those  of 
congenital  syphilis.  True  roseola,  completely  lacking  in  the  picture  of  con- 
genital syphilis,  is  occasionally  met  with  in  this  group. 

Acquired  syphilis  usually  takes  a  milder  course  than  the  congenital 
form,  and  consequently  its  recurrent  manifestations  are  especially  amenable 
to  treatment. 


XI. 

DISEASES  OF  THE  SKIN 

BY 

ERNST  MORO, 

Heidelberg. 

EDITED  AND  REVISED,  WITH  SUPPLEMENT,  BY 

HARRY  G.  IRVINE,  M.D., 

Associate  Professor  of  Dermatology  and  Syphilis,  Medical  School, 

University  of  Minnesota;  Director  of  the  Division  of  Venereal 

Diseases,  Minnesota  State  Board  of  Health. 

INTRODUCTION 

IN  looking  over  the  polyclinic  records  of  former  years,  we  find  the 
diagnoses  of  eczema,  lichen  urticatus,  impetigo,  etc.,  fully  as  often  as  we  do 
those  of  dyspepsia,  bronchitis,  angina,  and  the  like.  We  may  conclude  then 
that  diseases  of  the  skin  are  very  characteristic  to  childhood;  and,  not  only 
that,  we  even  find,  among  these  diseases  at  this  early  age,  varieties  and 
types  which  are  seldom  or  never  met  with  in  later  life.  For  this  reason 
alone,  a  clinical  knowledge  of  the  various  dermatoses  of  childhood  is  of 
great  importance  to  every  physician. 

To  this  consideration  must  be  added  another  and  probably  even  more 
important  argument.  Internal  disorders  are  often  revealed  very  distinctly 
upon  the  skin.  Thus,  in  the  infant,  exanthemata  of  extremely  discrete 
character  may  easily  clear  up  the  doubtful  diagnosis  of  syphilis  and  tuber- 
culosis. It  is  not  possible,  of  course,  to  make  a  positive  diagnosis  from  a 
single  lentil-sized  papule  on  the  forehead,  or  from  two  or  three  minute 
reddish-brown  papules  on  the  abdomen.  But  further  examination  is  di- 
rected by  these  important  discoveriesalong  certain  definite  lines  which  might 
not  have  been  followed  or,  at  least,  so  quickly  followed,  had  not  the  un- 
covered skin  shown  these  changes,  in  themselves  so  apparently  insignificant. 

A  large  number  of  such  examples  might  be  cited  and  each  show,  with 
equal  distinctness,  that  the  cutaneous  surfaces  offer,  indeed,  a  veritable 
mine  of  suggestive  symptoms  and  hence  that  their  changes  deserve  the 
closest  attention. 

Of  course,  the  relations  suggested  are  not  always  as  clear  as  in  syphilis  or 
tuberculosis.  It  would  be  extremely  difficult,  in  fact  to  place  the  proper 
value  upon  the  most  ordinary  dermatoses  of  childhood,  such  as  eczema 
and  urticaria,  had  not  clinical  experience  and  observation  taught  us  that,  at 
least  in  early  childhood,  even  these  exanthemata  must  be  regarded  as  expres- 
sions of  an  internal  disease  condition  hardly  second  to  rickets  in  frequency. 

This  definite  disease  condition  has  been  studied  and  can  be  differentiated 
clinically,  even  though  we  have  as  yet  no  definite  knowledge  of  its  true 

787 


788  TEXT-BOOK  OF  PEDIATRICS 

nature,  which  is  surely  often  congenital  and  sometimes  hereditary.  It 
appears,  therefore,  that  in  it  we  have  to  deal  with  an  abnormal  condition 
which  amounts  to  a  constitutional  anomaly  or  diathesis.  Since  its  chief 
characteristic  is  the  marked  tendency  to  reactive  inflammation,  the  condition 
is  suggestively  termed  the  inflammatory,  lymphatic  or  exudative  diathesis. 

In  the  conception  of  the  writer,  an  important  element  in  this  predisposi- 
tion of  infancy  is  the  excessive  and  often  severe  reaction  to  stimuli  of  the 
vasomotor  mechanism.  The  external  evidences  of  this  reaction  are  many 
and  it  is  a  largely  responsible  factor  in  the  development  of  skin  eruption. 

At  times  this  predisposition  becomes  manifest  even  during  the  first  few 
weeks  of  infancy.  It  is  seen  in  the  excess  of  the  physiologic  seborrhcea  of 
the  scalp.  The  abnormal  formation  of  these  scales  is  the  result  of  a  marked 
increase  in  the  secretion,  of  sebum.  The  term  exudative  diathesis,  proposed 
by  Czerny,  seems  suggestive,  in  the  very  meaning  of  the  word  exudation,  of 
the  common  characteristic  of  the  condition — an  abnormal  output  or  ex- 
cretion from  the  skin. 

Whether  every  form  of  eczema  and  every  exhibition  of  urticaria  in 
childhood  is  to  be  regarded  as  a  cutaneous  manifestation  of  this  diathesis 
remains  a  matter  of  opinion.  For  certain  infantile  eczematous  and  urticarial 
outbreaks,  without  any  apparent  exciting  cause,  this  view  has  indeed  a 
clinical  justification.  However,  this  is  a  matter  of  very  secondary  im- 
portance. The  essential  point  is  that  the  frequency  of  this  causative  re- 
lationship be  recognized  and  that  the  cases  be  treated  accordingly.  For 
the  constitutional  anomaly  in  question  is  not  absolutely  irreparable,  but 
yields  in  large  measure  to  suitable  methods  of  treatment.  If  the  physician 
is  successful  in  this,  he  not  only  frees  the  child  from  an  unpleasant  and 
annoying  skin  affection  but  probably  saves  it,  also,  from  many  other  seri- 
ous expressions  of  the  disease. 

The  writer  makes  this  brief  diversion  into  a  subject,  already  fully  dis- 
cussed in  another  part  of  this  work,  in  order  to  emphasize  the  point  that 
even  the  most  trivial  affection  of  the  skin  should  not  be  lightly  regarded; 
that  we  must  not  content  ourselves  merely,  in  each  and  every  case,  with 
purely  symptomatic  diagnosis.  He  wishes,  moreover,  to  suggest  the  espe- 
cial importance  of  this  conception  of  a  predisposition  in  the  domain 
of  dermatology. 

The  predisposition  to  skin  affections,  however,  is  not  always  congenital. 
It  may  be  acquired.  By  way  of  illustration  may  be  mentioned,  the  acquired 
predisposition  to  various  skin  conditions  of  a  non-specific  nature,  which 
result  from  infection  with  the  tubercle  bacillus.  If  this  acquired  predisposi- 
tion accidentally  falls  upon  the  soil  of  a  congenital  diathesis,  manifestations 
arise,  which  indicate  a  mixture  of  the  two  conditions  and,  as  a  result,  we 
have  the  characteristic  picture  of  scrofula,  with  its  extremely  peculiar  skin 
appearance  often  discernible  even  from  a  distance. 

Another  example  of  an  acquired  predisposition  to  certain  skin  affections 
is  seen  in  the  frequent  appearance  of  furunculosis  in  infants  who,  for  a  long 
time,  have  been  subject  to  disturbances  of  nutrition.  The  causal  agents 
of  these  multiple  skin  abscesses  are  pyogenic  cocci,  but  these  common  in- 


DISEASES  OF  THE  SKIN  789 

habitants  of  the  skin  would  not  have  caused  inflammation  and  suppura- 
tion had  they  not  found  a  favorable  soil.  It  is  immaterial  whether  gross 
chemical  alterations  of  the  cutaneous  tissue  have  produced  this  change  in 
the  soil,  as  suggested  by  Blochs,  or  whether  the  invasion  of  the  infective 
agent  is  to  be  considered  solely  as  an  expression  of  the  loss  of  the  natural 
resistive  power  of  the  body  as  a  whole.  However  this  may  be,  the  pyogenic 
cocci  serve,  as  in  the  group  of  impetigos,  as  causative  factors  of  the  cuta- 
neous inflammation. 

This  suggests,  again,  a  very  essential  point  in  the  pathogenesis  of  skin 
disorders,  the  causative  factor.  In  case  bacteria  enter  into  the  equation, 
the  problem  is  a  comparatively  simple  one.  These  micro-organisms  pene- 
trate the  skin  and  cause  an  inflammatory  reaction.  Of  course  this  is  not 
invariably  true,  since,  if  it  were,  the  same  opportunity  of  infection  or  an 
identical  inoculative  experiment  with  virulent  cocci  would  always  cause 
impetigo  or,  at  least,  an  inflammatory  reaction  in  all  skins.  Since,  however, 
we  find  that  only  a  certain  group  of  individuals  develop  an  impetigo  under 
given  conditions,  we  must  look  to  discover  in  them  a  special  predisposition 
of  the  organism,  to  attack. 

In  a  large  number  of  skin  affections,  moreover,  bacteria  do  not  enter  into 
the  consideration  at  all;  or  at  least  are  not  primarily  responsible.  The 
causative  factors  in  the  production  of  skin  diseases  must  be  of  other  origin. 
In  general  it  may  be  said  that  there  are,  doubtless,  stimuli,  either  of  endo- 
genous or  ectogenous  character,  that  is  of  internal  or  cutaneous  origin, 
which  potentialize  these  reactions. 

Internal  Stimuli. — A  fitting  example  of  a  dermatosis  of  endogenous 
character  is  found  in  the  exanthem,  which  is  frequently  seen  upon  the  skin 
after  the  injection  of  a  serum  foreign  to  the  species.  The  mode  of  action  of 
this  result  is  now  fairly  clear.  By  the  action  of  antibodies  formed  within 
the  organism,  a  toxic  principle  is  liberated  from  the  injected  substance 
(antigen)  which  may  provoke,  among  other  things,  an  inflammatory  reac- 
tion of  the  skin  (von  Pirquet,  Schick).  The  explanation,  for  want  of  a 
better,  will  probably  serve  for  the  appearance  of  a  large  number  of  acute 
exanthemata,  and  also,  within  certain  limits,  will  account  for  a  number  of 
so-called  toxic  eruptions  which  appear  as  individual  idiosyncrasies. 

Very  often  the  toxins  of  intestinal  bacteria  and  the  enterogenous  prod- 
ucts of  putrefraction  are  cited  as  the  internal  causes  of  the  dermatoses  of 
childhood.  While  it  is  possible  that  these  factors  play  some  part,  never- 
theless, too  much  stress  is  probably  laid  upon  their  importance.  While  it  is 
often  true  that  children  with  eczema  or  urticaria  are  habitually  constipated, 
it  may  by  no  means  be  considered  proved  that  fecal  retention  is  the  causa- 
tive agent  of  the  skin  condition.  The  clinical  observation  merely  goes  to 
show  that  obstipation  is  frequently  found  accompanying  an  existing  consti- 
tutional anomaly.  If,  as  the  result  of  an  increase  of  vegetable  food-stuffs 
in  the  dietary  and  a  decrease  of  milk,  the  obstipation  disappears,  together 
with  the  dermatosis,  the  coincidence  may  be  properly  attributed  to  the 
favorable  influence  of  the  improved  method  of  feeding  upon  the  digestion 
in  general.  Indeed,  the  occasional  beneficial  result  obtained  from  catharsis 


790  TEXT-BOOK  OF  PEDIATRICS 

and  from  the  use  of  the  so-called  intestinal  antiseptics,  the  value  of  which 
will  not  be  discussed  here,  may  be  nothing  more  than  the  effect  of  a  tem- 
porary reduction  of  the  dietary. 

Moreover,  there  are  certain  dermatoses,  of  familiar  and  widespread  oc- 
currence, which  not  uncommonly  appear  in  children  with  functional 
disturbances  of  the  organs  of  internal  secretion,  or  at  puberty  when  the 
genital  organs  are  maturing.  In  these  cases,  toxic  substances  of  endogenous 
origin  probably  serve  as  common  factors.  At  present,  however,  there  is  so 
little  positive  knowledge  of  this  relationship  that  we  must  content  ourselves 
with  the  mere  mention  of  the  matter. 

Practically  the  same  thing  is  true  of  infantile  eczema,  the  skin  disease 
of  greatest  clinical  importance  in  childhood.  We  have  already  emphasized 
the  fact  that  the  basic  cause  of  its  appearance  is  to  be  found  in  the  consti- 
tutional anomaly.  Nevertheless,  in  spite  of  the  most  persistent  research,  no 
definite  knowledge  as  to  the  nature  of  this  relationship  has  been  achieved. 
Clinical  experience  would  indicate  that  overfeeding  of  milk  has  an  impor- 
tant bearing.  The  endogenous  toxin  causative  of  eczema  has  been  ascribed 
to  one  or  another  inappropriate  component  of  the  food,  e.  g.,  fat  or  salt.  At 
the  present  time,  however,  it  is  impossible  to  make  any  definite  state- 
ment of  results  obtained  by  the  removal  of  any  such  supposedly  injurious 
component  of  the  dietary.  Under  a  marked  reduction  of  the  milk-supply, 
the  conditions  have  not  always  permitted  us  to  form  precise  conclusions 
of  benefit  or  the  reverse. 

External  causes,  doubtless,  play  a  large  part  in  the  causation  of  the 
dermatoses.  That  these  external  injuries  suffice  to  induce  inflammatory 
skin  affections  is  exemplified  by  the  wheals  of  nettlerash  and  the  urticaria 
following  insect  bites.  Indeed,  the  most  important  factor  often  seems  to  lie 
in  the  sensory  irritation.  This  is  not  surprising  if  we  remember  that  the 
sensory  nerve  termini  represent  the  receiving  organs  of  the  reflex  neurones  of 
the  peripheral  vasomotor  mechanism. 

A  good  example  of  an  eczematous  dermatosis  dependent  upon  essentially 
external  causes  is  presented  in  the  inflammation  of  the  skin,  generally 
recognized  under  the  term  intertrigo.  The  external  irritation  of  the  nates 
by  the  diaper,  wet  with  the  urinary  and  fecal  discharges  and  of  the  neck 
kept  moist  by  the  acid  vomitus,  staining  the  collar  of  the  infant's  dress 
which  constantly  rubs  the  skin,  are  etilogic  factors  of  the  first  degree.  With 
the  removal  of  these  causes,  the  condition  itself  disappears,  but,  of  course, 
not  with  equal  rapidity  in  all  children.  If  an  intertrigo  obstinately  persists, 
in  spite  of  proper  external  treatment,  or  if  it  reappears  over  extensive  areas 
upon  the  slightest  provocation,  it  should  always  arouse  suspicion,  for  which 
experience  affords  ample  ground  that  it  is  an  early  indication  of  the  presence 
of  exudative  diathesis  and,  as  such,  is  apparently  as  important  as  the  de- 
velopment of  eczema  or  the  unexpected  appearance  of  strophulus. 

An  important  and  significant  external  influence  which,  in  the  presence 
of  an  existing  predisposition,  very  often  causes  the  development  of  derma- 
toses, is  scratching.  The  dermatosis  in  this  case  is  not  always  and  neces- 
sarily produced  by  the  transmission  and  implantation  of  pus  cocci,  it 


DISEASES  OF  THE  SKIN  791 

results  rather  from  the  sensory  irritation  caused  by  the  scratching.  This  is 
very  clearly  noted  in  infants  affected  by  constitutional  eczema  of  the  face; 
when,  as  a  result  of  persistent  scratching,  new  eruptions  appear  in  various 
parts  of  the  body,  until  the  entire  skin  is  finally  covered  by  constantly 
enlarging  and  multiplying  patches  of  eczema.  In  urticaria,  this  is  even  more 
clear  than  in  eczema.  How  apparent  then  is  the  importance  of  the  preven- 
tion of  scratching  in  these  skin  diseases,  even  though  such  prevention 
requires  the  exercise  of  force. 

Although  scratching  of  the  eczematous  skin  be  prevented  as  far  as 
possible,  other  external  sources  of  irritation  arise  which  may  affect  the  skin 
in  a  similar  manner  and  serve  to  spread  the  dermatosis.  Thus,  the  tense 
vesicle  itself  itches,  probably  because  it  causes  pressure  upon  the  nerves  in 
the  deeper  tissues.  So  also  the  dry  seborrhceic  scales,  lying  upon  the 
exposed  corium,  excite  itching.  Bacterial  products,  always  present  in  large 
quantities,  cause  irritation;  while  in  weeping  eczema  the  exudate  flowing 
over  the  papillae  is  intensely  irritating.  It  is  incumbent  upon  the  clinician, 
therefore,  to  guard  against  these  external  injuries  as  far  as  possible  and  the 
local  treatment,  mainly  directed  to  this  end,  is  theoretically  inspired  and 
practically  justified  by  the  object  in  view. 

The  itch-mite  and  the  head  louse  are  certainly  not  regarded  as  the 
causative  factors  of  an  extensive  dermatosis  on  account  of  any  toxin  they 
excrete  or  even  because  of  their  bites,  but  chiefly  on  account  of  the  un- 
bearable itching  to  which  their  host  is  subjected.  A  general  reflex  eczema 
of  the  scalp,  which  may  be  diagnosed  almost  at  sight,  and  virtually  repre- 
sents a  distinct  disease  in  itself,  appears  only  after  the  finger-nails  have 
thoroughly  lacerated  the  skin. 

Doubtlesse  exposure  to  light,  temperature,  wind  and  other  climatic  in- 
fluences, also  plays  an  important  part  in  the  causation  of  skin  disorders. 
It  may  be  that  the  predilection  of  infantile  eczema  for  exposed  parts  of  the 
body  is  relational  to  these  influences.  The  peculiar  sensitivity  of  the  cu- 
taneous vasomotor  mechanism  again  comes  into  consideration  at  this  point. 

With  the  superficial  and  gross  picture  of  these  dermatoses  of  childhood, 
contrasted  in  our  mind  with  the  still  imperfect  knowledge  we  possess  of 
their  underlying  conditions,  it  should  be  apparent  that  the  three  cardinal 
guiding  points,  predisposition,  internal  causation,  and  external  injury, 
must  always  be  borne  in  mind.  It  is  especially  necessary  that  we  remember 
and  be  governed  by  these  considerations  in  the  treatment  of  these  diseases. 

ECZEMA 

Eczema  is  a  mild  catarrh  of  the  skin,  a  superficial  cutaneous  inflamma- 
tion with  very  active  serous  and  cellular  excretion.  The  inflammation 
arises  in  the  corium,  and  in  distinction  from  other  forms  of  dermatitis, 
begins  in  small  punctate  discrete  foci.  The  process  rapidly  extends  to  the 
epithelium  and  the  small  primary  lesions  appear  on  the  surface  in  the  form 
of  individual  papules  or  vesicles.  These  initial  forms  are  essentially  char- 
acteristic of  eczema,  but  the  picture  changes  easily  and  rapidly.  The 


792  .     TEXT-BOOK  OF  PEDIATRICS 

individual  foci  become  confluent  and  soon  present  an  extensive  inflamed 
surface.  Still  at  some  point  in  the  periphery,  where  the  process  is  less 
advanced,  it  is  usually  possible  to  find  one  or  more  of  the  primary  eczema 
papules.  Discrete  papules  or  vesicles,  superficial  extension  and  itching,  are 
the  pathognomonic  signs  of  the  varied  group  of  skin  affections  which  we 
term  eczema. 

In  the  course  of  an  eczema,  persisting  unrestrained  for  a  long  time,  it  is 
possible  to  distinguish  various  stages.  Theoretically,  their  definite  syste- 
matic arrangements  has  no  great  value.  The  local  treatment,  however,  is 
so  dependent  upon  the  stage  of  progress  at  which  the  eczematous  inflamma- 
tion is  found,  that,  for  purely  practical  purposes,  it  appears  necessary  to 
recognize  and  discuss  these  several  divisions  of  the  process,  in  the  order  of 
their  development: 

1.  The  erythematous  stage,  eczema    eryihematosum;    the    skin    being 
slightly  reddened,  edematous  and  tense. 

2.  The  papular  stage,  eczema  papulosum;  marked  by  the  appearance  of 
small  reddish  papules  upon  the  skin,  which  they  become  confluent  and  form 
slightly  raised  plaques. 

3.  The  vesicular  stage,  eczema  vesiculosum;  showing  the  development 
of  a  serous  exudate  in  the  papules. 

4.  The  impetiginous  stage,  eczema  pustulosum;  with  secondary  infection 
and  suppuration  of  the  vesicles. 

5.  The  weeping  stage,  eczema  madidans;  when  the  pustules  rupture  or 
are  scratched  open,  forming  many  small  openings  in  the  horny  layer  of  the 
skin,  or  the  entire  horny  layer  is  loosened  so  that  the  rete  lies  exposed.    In 
consequence,  there  is  marked  weeping  on  the  surface,  a  fact  which  suggests 
the  name. 

6.  The  encrusted  stage,  eczema  crustosum;  the  exudate  drying  rapidly,  in 
so  far  as  it  is  not  removed,  and  resulting  in  the  formation  of  crusts  and  scabs. 

7.  The  squamous  stage,  eczema  squamosum;  when,  in   consequence  of 
excessive  cell  proliferation,  an  increased  desquamation  of  the  epithelial 
cells  occurs. 

As  a  rule,  eczema  squamosum  is  the  terminal  stage  of  the  disease  and  in 
wholly  uncomplicated  cases  tends  to  healing  without  scar  formation. 

Eczema  may  go  through  all  these  stages  in  the  order  recited.  In  other 
instances  the  disease  may  pass  directly  from  the  first  or  second  stage  to  the  last. 

The  classification  of  the  eczemas  of  childhood  into  acute  and  chronic 
forms  meets  with  certain  difficulties.  Such  a  classification  gives  a  wide 
range  to  the  judgment  of  the  individual  observer.  Usually  an  acute 
course  marks  all  those  forms  of  eczematous  inflammation  of  the  skin  in  the 
etiology  of  which  external  irritation  is,  by  far,  the  most  pronounced  factor 
and  which,  being  removed,  the  eczema  heals  quickly  and  completely.  On 
the  other  hand,  a  more  chronic  course  is  to  be  expected  of  those  forms  of 
eczema  which  are  chiefly  dependent  upon  internal  causes.  Unless  these  are 
completely  removed,  and  this  is  very  frequently  beyond  the  power  of  the 
physician — new  irritations  and  reactions  repeatedly  complicate  the  eczema 
in  an  unlimited  series  of  recrudescences. 


DISEASES  OF  THE  SKIN  793 

As  examples  of  eczematous  dermatites  running  an  acute  course,  we  may 
note  the  various  forms  of  intertrigo,  eczema  solare,  and  the  so-called  suda- 
minous  eczemata.  However  it  is  better,  perhaps,  to  classify  these  forms  as 
artificial  eczemata  and  to  reserve  the  term  acute  eczema  for  those  relatively 
rare  cases  of  more  or  less  widespread  dermatitis,  which  appear  very  sud- 
denly, often  with  initial  fever,  moderate  itching,  and  marked  redness;  and 
in  their  further  course  soon  disclose  their  eczematous  nature.  The  points  of 
predilection  for  these  acute  eczemata  are  the  face,  the  nose,  the  ears  and  the 
region  of  the  genitals.  The  turgescent  redness  and  the  fairly  sharp  margins 
which  are  peculiar  to  these  circumscribed  inflammations  cause  a  very  close 
resemblance  to  erysipelas.  This  likeness  is  further  emphasized  by  the  very 
frequent  appearance,  in  some  part  of  the  inflamed  area,  of  a  large  tense  bleb 
filled  with  serous  fluid.  Nevertheless,  the  redness  is  not  so  intense  nor  the 
surface  so  glistening  as  in  erysipelas,  while  the  swelling  is  much  more 
marked  and  the  vesico-papular  form  of  eruption  is  predominant.  Its 
course  is  briefer,  entirely  favorable  and  it  is  hardly  ever  influenced  to  any  ex- 
tent by  local  treatment;  e.  g.,  cold  applications,  lead  water  solutions  or 
bland  ointments. 

INTERTRIGINOUS  ECZEMA 

This  is  frequently  called  intertrigo  and  is,  especially  in  infants,  a  very 
prevalent  skin  affection. 

The  clinical  picture  permits  division  into  two  principle  types : 

1.  The  intertrigo  of  fat,  overfed  and  frequently  constipated  infants. 

2.  The  intertrigo  of  dyspeptics. 

In  the  first  group,  it  is  not  the  extent  of  the  inflamed  areas  which  is 
marked,  but  rather  the  locations  between  the  genitals  and  the  thighs,  in  the 
groin,  the  axillae,  at  the  elbow  and  on  the  neck  where  there  are  heavy  folds  of 
skin  produced  by  its  excessive  panniculus.  The  close  contact  of  these  fatty 
folds  prevents  the  evaporation  of  the  skin  excretions  and  these  parts  re- 
main constantly  moist.  If  in  addition  the  clothing  is  too  warm  and  close- 
fitting,  intertrigo  can  hardly  be  avoided  in  these  "prize  babies."  This 
form  of  intertrigo  has  more  of  the  character  of  a  simple  dermatitis.  Pa- 
pules and  vesicles  are  not  usually  seen.  Dyspeptic  disturbances  are  not 
present  in  these  cases  but  they  commonly  show  an  obstinate  constipation. 

The  second  form  differs  essentially,  in  that,  although  it  may  occa- 
sionally be  seen  in  obese  children,  it  is  always  accompanied  by  symptoms  of 
dyspepsia  or  is,  at  least,  ushered  in  with  them.  He  who  understands  the 
character  of  thrush,  will  not  be  surprised  to  find  that  patches  in  the  mouth 
frequently  accompany  this  form  of  the  skin  disorder. 

Diarrhceal,  acid  stools,  an  irritating  urine  frequently  of  ammoniacal 
odor,  and  clothing  soaked  by  quantities  of  vomited  sour  milk  are  to  be  con- 
sidered chief  among  the  etiologic  factors.  Accordingly,  the  nates,  the  skin 
about  the  external  genitalia,  the  neck  (front  and  sides)  and  the  chin  are  the 
sites  of  predilection.  At  the  height  of  the  inflammatory  process,  these 
affected  areas  are  of  a  fiery  red  color,  hot,  glistening  and  swollen.  They  are 
tense  and  very  sensitive  to  the  touch.  Usually  papules  and  vesicles  are 


794  TEXT-BOOK  OF  PEDIATRICS 

discoverable  only  at  the  beginning  of  the  attack,  and  then  soon  disappear 
in  the  diffuse  erythema. 

The  severest  grade  of  this  dermatitis  is  seen  in  pale,  feeble  and  badly 
neglected  infants.  In  these  cases,  an  eyrthema  is  often  seen  continued  over 
the  back,  abdomen,  legs  and  heels;  and  if,  in  addition,  there  is  an  intertrigo 
of  the  neck,  it  is  difficult  to  discover  a  spot  of  unaffected  skin.  If  the  pa- 
pules and  vesicles  around  the  nates  are  scratched,  numerous  erosions  and 
excoriations  remain  often  in  puzzle-shaped  areas  after  the  diffuse  inflam- 
mation has  subsided. 

It  should  be  noted  that  neither  this  condition,  nor  the  round,  light  red, 
scaly,  somewhat  indurated  plaques,  which  sometimes  persist  over  the  area 
of  a  previous  intertrigo  (Finkelstein),  the  so-called  plaques  erosive,  or 
eryiheme  syphiloide  posterosiv,  of  the  French  authors,  have  any  connection 
with  lues. 

In  the  treatment  of  intertrigo,  far-reaching  prophylactic  measures  are, 
of  course,  the  most  important  thing  and  consequently  the  condition  is  very 
uncommonly  seen  in  properly  conducted  institutions  for  infant  care.  Proper 
methods  of  feeding  play  a  very  essential  part  in  its  prevention.  This 
is  also  true  of  already  existing  intertrigo,  especially  of  the  second  form 
which  is  found  in  combination  with  dyspepsia.  If  we  are  successful  in 
removing  the  digestive  disturbance,  the  intertrigo  also  quickly  disappears. 
In  weeping  intertrigo,  the  influence  of  the  dietetic  treatment  may  be  assisted 
by  lightly  painting  the  surface  with  a  5  per  cent,  solution  of  silver  nitrate, 
once  each  day,  and  by  the  free  use  of  dusting  powder.  The  application  to 
the  affected  areas  of  a  zinc  paste  is  also  to  be  recommended  in  spite  of 
numerous  theoretical  objections  urged  against  it.  It  should  be  employed,  at 
least,  during  the  night  in  order  to  protect  the  inflamed  parts  from  further 
irritation.  Inasmuch  as  intertrigo  corresponds  markedly  to  the  seborrhceic 
eczemas  of  adults,  antiseborrhceics  such  as  sulphur,  resorcin  and  salicylic 
acid  are  of  value.  After  application  of  silver  nitrate,  the  following  salves 
will  be  found  of  value;  1  per  cent,  acid  salicylic,  3  per  cent,  lac  sulphur  in 
either  petrolatum  or  modified  zinc  paste,  as 

Acidi  Salicylic 0.3 

Sulphuris-Lac 0.9 

Zinc  Oxidi 

Amyli aa 5.0 

Petrolati  Flavum 20.0 

If  large  areas  of  the  corium  are  exposed,  treatment  similar  to  that  used  in 
burns  of  the  second  degree  is  indicated.  Lead  water  fomentations  and  lini- 
mentum  calcis  are  very  useful  for  this  purpose.  Wet  packs  of  2  per  cent,  re- 
sorcin are  frequently  very  valuable. 

Sometimes  even  these  measures  do  not  give  the  desired  results.  The 
intertrigo  proves  very  obstinate.  On  the  neck,  over  the  nape  of  the  neck 
and  on  the  nates  it  may  involve  extensive  areas  which  are  often  very  sharply 
marginated.  In  some  regions,  especially  over  the  flexor  surfaces  of  the 
elbows,  the  eruption  is  likely  to  become  chronic.  Almost  always  there  is 
an  extremely  marked  tendency  to  desquamation  and  seborrhcea.  The  in- 


DISEASES  OF  THE  SKIN 


795 


flamed  areas  of  the  skin  are  covered  with  numerous  and  extensive  lam- 
ellar scales  and  with  seborrhceic  exudates  which  on  the  scalp  often  form  a 
thick  cap-like  crust.  Children,  so  affected,  are  delicate  and  pale,  of  defi- 
cient turgor,  of  flabby  musculature  and  show  insufficient  gains  in  weight. 
They  are  almost  always  to  be  classed  among  the  subjects  of  exudative 
diatheses ;  and  in  their  treatment  much  more  may  usually  be  accomplished 
by  dietetic  measures  than  by  external  treatment  alone.  The  beginning  of 
such  intertrigos  is  almost  always  to  be  traced  to  an  acid  dyspepsia. 

ERYTHRODERMIA 

Several  years  ago,  Leiner  described  a  peculiar  general  dermatosis  under 
the  name  of  desquamative  erythrodermia.  This  condition  has  many 
points  in  common  with  the  form  of  intertrigo  just  described;  and  should 
probably  be  regarded  merely  as  its  extreme  type.  It  consists  in  a  general 


Flo.  216. — Desquamative  erythrodermia  (from  intertrigol  moderate  degree, 
complete  recovery  during  second  week.     Breast-fed  infant. 

inflammation  of  the  skin,  with  intensive  desquamation  of  the  epidermis  and 
a  very  marked  seborrhcea  of  the  scalp.  Leiner  leaves  the  question  of  the 
etiology  of  this  condition  an  open  one,  but  suggests  the  hypothesis  that  it  is 
an  auto-toxemic  erythema  doubtless  closely  related  to  the  intestinal  dis- 
turbances always  found  in  these  children.  The  preponderance  of  breast-fed 
infants  among  them  and  the  high  mortality  (one-third  of  the  cases,  Leiner), 
is  remarkable. 

If  careful  inquiry  into  the  history  of  these  children  is  made,  it  will  be 
found  that  in  almost  every  case,  the  condition  is  preceded  by  diarrhoea  and 
intertrigo,  and  usually  accompanied  by  thrush.  The  only  peculiar  feature 
is  the  extremely  rapid  spread  of  the  dermatitis  over  the  entire  body  and  the 
remarkably  intense  general  seborrhcea  which  seems,  indeed,  to  give  its 
clinical  picture  something  of  an  individuality. 

The  disease  is  to  be  considered  a  general  dermatitis  following  inter- 
trigo which  may  reach  this  extreme  degree  in  children  with  a  distinct  status 
seborrhceicus.  The  lack  of  discrete  papules  is  not  sufficient  reason  for 


796  TEXT-BOOK  OF  PEDIATRICS 

excluding  entirely  this  dermatosis  from  the  group  of  eczemata,  since  we  so 
often  miss  the  primary  element  of  eczema  even  in  the  course  of  the  us- 
ual intertrigo. 

If  the  dermatosis  occurs  in  the  breast-fed  infant,  the  first  indication  is  for 
mixed  feeding.  Good  results  are  usually  obtained  with  milk  and  gruel  mix 
tures  or  with  buttermilk.  The  main  object  of  the  treatment,  in  fact, 
should  be  the  relief  of  the  dyspepsia.  Beyond  this,  we  should  employ 
measures  to  soften  the  dry  scaly  skin.  This  may  be  readily  accomplished 
by  means  of  oil  packs.  Later  on,  the  parts  should  be  bandaged  with  zinc 
oxide  in  oil,  cod-liver  oil,  or  zinc  ointment;  and,  still  later,  dusted  with 
talcum  powder.  The  dermatosis  heals  with  relative  rapidity  and  without 
leaving  any  traces  whatever  upon  the  skin.  So  far,  the  writer  has  not  seen 
any  fatal  cases,  although  this  may  be  a  purely  accidental  matter. 

CONSTITUTIONAL  ECZEMA  OF  INFANTS 

The  severe  seborrhoea,  which  at  the  height  of  the  disease  covers  the 
bright  red  skin  of  erythrodermic  children  with  innumerable  scales,  and  the 
thick  seborrhceic  crust  on  the  scalp,  suggest  an  abnormal  constitutional 
quality  as  the  basis  also  of  this  type  of  dermatitis.  This  constitutional 
anomaly  is  particularly  apparent  in  the  very  common  and  clinically  impor- 
tant group  of  infantile  eczemata  which,  as  a  matter  of  fact,  have  long  been 
designated  as  of  constitutional  type. 

According  to  Feer,  two  clinical  varieties  of  this  condition  may  be  dif- 
ferentiated: (1)  The  weeping,  crusted  eczema  of  the  head;  and  (2),  the 
disseminated  dry  eczema. 

The  first  form,  by  far  the  most  common,  affects  chiefly  fat,  overfed 
children,  while  the  second  affects  chiefly  emaciated  and  sickly  children.  All 
infantile  eczemas  cannot,  of  course,  be  classified  definitely  under  these  two 
primary  types  which,  strictly  speaking,  represent  the  terminal  conditions  in 
an  uninterrupted  course.  Transitions  from  the  first  into  the  second  form 
appear  quite  commonly.  Nevertheless,  this  classification  has  a  certain 
distinctive  merit  since  the  two  groups  have  a  different  prognosis  and  the 
dietetic  treatment  with  the  first  form  seems  to  give  better  results  than  with 
the  second. 

In  the  weeping  crusted  eczema  of  the  head  the  eruption  is,  for  a  time  at 
least,  confined  strictly  to  the  face  and  scalp.  The  skin  of  the  rest  of  the  body 
is  exceptionally  free  from  any  efflorescence,  pink  and  velvety,  giving  a 
distinct  contrast  to  the  face  where  the  closely  crowded  eczematous  crusts 
leave  hardly  any  unaffected  area. 

The  most  frequent  starting  points  of  this  eczema  are  two  local  sebor- 
rhoeic  processes,  a  seborrhcea  of  the  scalp  and  the  dry  scaly  lesions  of  the 
cheeks.  From  here  the  eczema  spreads  more  or  less  rapidly  to  the  back  of 
the  neck,  the  temples  and  the  forehead.  The  initial  papules  and  vesicles 
are  scratched  open  or  burst,  and  through  an  inevitable  secondary  infection 
are  changed  to  pustules.  These  dry  rapidly,  scab,  and  present  the  picture  of 
an  impetiginous  or  crusted  eczema.  The  secretion  from  the  deeper  layers 
continues,  the  crusts  are  sloughed  or  torn  off  by  scratching,  and  here  and 


DISEASES  OF  THE  SKIN 


797 


there  the  bright  red,  weeping  and  bleeding  corium  lies  exposed.  In  mild 
cases,  the  nose,  mouth  and  chin  are  not  involved;  but  in  others  the  crusts 
are  especially  thick  about  the  margins  of  the  mucous  membranes,  and  then 
the  lids  are  often  so  markedly  affected  that  the  eyes  can  hardly  be  opened. 

As  the  disease  progresses,  the  lymph  nodes  of  the  submaxillary  region 
and  of  the  anterior  and  posterior  cervical  chains  regularly  become  enlarged. 
vSuppuration  is,  however,  quite  uncommon.  In  children  who  are  given  to 
much  scratching,  separate  placques  of  eczema  may  appear  later  upon  the 
extremities  and  the  trunk;  but  even  in  these  cases  the  eczema  of  the  head 
remains  the  most  conspicuous  feature. 

This  head  eczema  occurs  in  breast-fed,  as  well  as  artificially-fed  infants 
and  usually  during  the  first  half-year. 

From  the  prognostic  viewpoint  it 
is  instructive  to  note  that  in  some 
countries  this  exanthem  is  known  as 
"  the  forty  weeks  eruption,"  because, 
as  a  rule,  it  lasts  for  that  length  of 
time.  It  is  well,  therefore,  to  prepare 
the  parents  for  a  long  period  of 
laborious  care  and  patient  waiting. 

Disseminated  dry  eczema  is 
found  almost  exclusively  in  bottle- 
fed  infants  who  do  not  show  any 
special  tendency  to  put  on  any  great 
amount  of  fat.  They  are  often  of  a 
pale,  emaciated  and  flabby  type. 
The  condition  is  one,  which  appears 
at  a  later  period  than  eczema  of  the 
head,  and  usually  in  the  latter  half 

,   , ,  ,      .    , ,        n 

Or  toward  the  end  OI    the   hrSt  year. 

The  head  is  not  entirely  free  from 
the  disease  even  in  this  form,  but 

the  most  characteristic  feature  is  seen  in  the  presence  of  numerous  dis- 
seminated, dry,  indurated  and  fairly  well  marginated  plaques  on  the  trunk 
and  on  the  extremities.  This  form  of  eczema  is  often  exceedingly  persistent 
and  from  the  standpoint  of  therapy  more  difficult  to  influence  than  the 
eczema  of  the  head.  This  depends  probably  not  so  much  upon  the  local 
process  as  upon  the  constitutional  condition  which  seems  to  be  worse  than 
in  those  children  subject  to  the  head  eczema. 

The  metabolism  of  eczematous  children  shows  no  characteristic  devia- 
tions from  the  normal.  Very  recently,  however,  certain  positive  facts 
have  been  recorded,  which  are  of  importance.  It  has  been  shown,  in  the 
first  place,  that  the  limit  of  assimilation  of  sugars,  and  especially  of  maltose 
is  too  low,  and  that  a  diet  rich  in  carbohydrates  readily  leads  to  alimentary 
glycosuria  (Aschenheim).  Further,  an  increased  and  abnormal  tendency  to 
water  and  chlorine  retention,  followed  by  an  excessively  rapid  excretion  of 
the  retained  chlorine  upon  the  reduction  of  the  chlorine  in  the  food  has  been 


FIG.  217. — Crusty,  moist  eczema  of  the  head. 
Conjunctiva  and  nose  not  affected  in  distinction 
from  scrofula.  (Gisela  Children's  Hospital,  Mu- 


798  TEXT-BOOK  OF  PEDIATRICS 

demonstrated  (Freund  and  Menschikoff).  This  last  observation  agrees 
with  that  of  Czerny  that  in  exudative  diathesis  there  is  a  congenital  defect 
in  the  chemism  of  those  tissues  which  permits  a  great  variation  in  the 
water  content. 

Clinically,  eczema  is  often  found  to  disappear  either  entirely  or  in  part, 
during  rapid  losses  of  weight,  especially  during  the  course  of  acute  febrile 
diseases.  This  phenomenon  may  be  attributed,  in  part,  to  a  drying  of  the 
skin  as  a  result  of  the  large  loss  of  water;  and  still  further  to  the  influence 


FIG.  218. — Seborrhceic  dermatitis  of  scalp  (courtesy  of  Richard  L.  Sutton). 

of  the  fever  itself  in  diminishing,  in  large  measure,  the  disposition  of  the  skin 
to  inflammatory  reaction. 

The  supposition  that  overfeeding  plays  an  important  role  in  the  patho- 
genesis  of  infantile  eczema  is  not  a  new  one.  This  is  suggested  indeed,  in 
the  application  to  its  cardinal  features  of  the  terms  "crusta  lactea"  and 
"milk  rash,"  by  which  physicians  and  laity  alike  have  designated  infantile 
eczema  for  centuries;  terms  which  doubtless  arose  from  the  conception  that 
the  eruption  stood  in  close  relationship  to  an  excessive  milk  diet.  Czerny, 
in  recent  times,  was  the  first  to  recall  attention,  with  some  emphasis,  to  this 
fact.  It  is  possible  that  quality  as  well  as  quantity  is  to  be  considered  in 
certain  individuals.  Nothing  definite  of  this  is  known  however  even  to-day. 
Perhaps  one  must  also  consider  the  correlation  of  the  various  components 
of  the  food  especially  the  fat  and  salts. 


DISEASES  OF  THE  SKIN 


799 


Dietetic  Treatment. — In  the  study  of  the  dietary,  two  principal  points 
should  be  borne  in  mind:  (1)  The  avoidance  of  excessive  increases  in 
weight;  and  (2)  the  eliminations,  so  far  as  possible,  of  milk  from  the  food. 

It  is  self-evident  that  these  precepts  are  more  easily  obeyed  with  fat 
overfed  children  who  have  passed  the  first  year,  than  with  young  and 
emaciated  nurslings.  In  every  instance  the  aim  should  be  to  reduce  the 
quantity  of  milk  to  the  minimum  compatible  with  the  individual  welfare, 
replacing  the  calories  thus  sacrificed 
by  the  addition  of  gruels  and  flour. 
The  temporary  use  of  skim-milk  is 
to  be  recommended.  In  children 
who  are  in  the  second  half-year, 
milk  may  be  left  out  of  the  diet  for 
several  weeks  without  injury,  sub- 
stituting a  varied  menu  of  flour 
soups  and  gruels,  fruits  and  fruit 
juices  and  fresh  vegetables. 

Eggs  are  to  be  prohibited 
(Czerny),  and  unfavorable  results 
are  reported  with  broths  (Feer). 

Breast-fed  infants  should  be 
permitted  to  continue  nursing.  For 
fat  babies  the  number  of  feedings 
should  be  reduced  to  four.  After 
the  third  month,  the  breast  should 
be  given  only  three  times  a  day, 
adding  gruel  to  the  diet,  under  care- 
ful control  by  daily  weighings. 

All  these  dietetic  expedients 
must  be  undertaken  with  extreme 
care  in  the  weak,  emaciated,  bottle- 
fed  infant;  for  the  treatment  can 
hardly  be  considered  successful, 
though  the  eczema  disappear, 
should  the  child  eventually  succumb. 

The  local  treatment  as  suggested 
in  the  introductory  chapter,  is  an 
essential  part  of  the  management  of  eczema.  Its  detail  depends  entirely 
upon  the  stage  at  which  the  disease  is  presented.  Before  taking  up  its 
several  features,  however,  it  may  be  well  to  cite  the  principles  of  especial 
practical  importance  upon  which  the  local  treatment  of  the  disease  is  based. 

a.  Scratching  must  be  prevented  as  rigidly  as  possible.  It  may  not  be 
possible  to  prevent  scratching  entirely.  The  infant  will  inevitably  find 
new  ways  of  gratifying  the  irresistible  impulse.  Nevertheless,  all  possible 
precautions  should  be  taken.  The  finger-nails  should  be  trimmed  as  short 
as  may  be;  the  hands  may  be  bandaged  or  covered  with  mittens.  Splints, 
over  the  elbow-joints;  the  fastening  of  the  hands  to  the  bed;  the  pinning 


FIG.  219. — Disseminate  eczema  (en  plaques). 


800 


TEXT-BOOK  OF  PEDIATRICS 


of  the  sleeves  fo  the  bedclothes,  may  prevent  the  child  from  scratching 
its  face.  Care  must  be  taken  to  prevent  scratching  even  when  changing 
the  bandages. 

6.  The  eczematous  areas  of  the  skin  should  be  cleansed  either  with  an 
alcoholic  solution  with  2  per  cent,  of  salicylic  or  boric  acid,  or  with  petrola- 
tum. (Acid  salicylic  2.0,  spiritus  vini  rectificatissimus  60  per  cent.,  100.0.) 
Water  and  soap  are  often  irritating.  The  chief  objection  to  their  use  is  that 
the  skin  cannot  be  thoroughly  dried  after  their  use.  The  healthy  skin  can 
be  washed  and  dried,  as  usual. 

c.  The  application  of  ointments  and  pastes  is  not  in  itself  sufficient. 
They  must  be  covered  with  a  firm  bandage  or,  in  mild  cases,  may  be 

thoroughly  covered  with  powder. 

The  ointment  or  paste  should 
be  thickly  applied  upon  a  very  soft 
sterile  cloth,  which  may  be  held  in 
place  by  the  ordinary  gauze  band- 
age. Sterile  absorbent  lint  is  best 
used  with  the  ointment  applied  to 
the  fuzzy  side. 

d.  So  long  as  the  desired  results 
are  attained  with  any  remedy  it 
should  be  continued.    In  fact,  it  is 
better  not  to  change  a  chosen  course 
of  treatment  any  oftener  than  is 
absolutely  necessary. 

e.  In  a  general  way,  the  direction 
to  treat  weeping  eczema  with  drying 
methods  (pastes,  silver  nitrate,  etc.), 
and  the  dry  eczema  by  moist  meth- 
ods (fatty  ointments,  etc.),  serves 
usefully.    It  is  a  mistake  to  apply 
the  latter  to  exuding  surfaces;  the 

exudate  collects  beneath  the  covering  ointment  and  is  the  more  irritating 
because  of  the  retention. 

/.  Tar  should  be  applied  with  great  caution. 

It  is  best  to  test  the  preparation  first  upon  small  areas.  The  remedy  is 
contraindicated  as  long  as  the  eczema  is  in  the  early  papulo-vesicular  or 
encrusted  stages.  This  is  especially  true  of  eczema  of  the  face.  .Recently 
crude  tar  as  obtained  directly  at  the  gas  house  has  come  into  use  and  it  is 
rather  an  exception  to  this  rule,  inasmuch  as  it  can  frequently  be  very 
successfully  applied  to  acute  eczemas.  It  may  be  used  as  an  ointment: 

Crude  Tar 2.0         Tarrolin 4.0 

Zinc  Oxide 2.0         Yellow  Petrolatum 16.0 

Starch 12.0 

or  painted  on  daily  in  the  following  mixture. 

Crude  Tar  Acetone  Collodion        aa 

In  young  children  with  generalized  cases,  it  is  well  to  go  cautiously. 


FIG.  220. — Face  mask  and  arm  cuffs  for  treatment 
of  facial  eczema. 


DISEASES  OF  THE  SKIN  801 

g.  If  the  eczema  has,  clinically  speaking,  disappeared  a  rational  after- 
treatment  of  the  formerly  affected  skin  areas  should  be  undertaken. 

The  avoidance  of  mechanical  irritation;  the  careful  use  of  soap  and 
water;  the  brief  employment  of  bran  baths,  followed  by  careful  applications 
of  cold  cream,  promote  the  gradual  healing  and  hardening  of  the  skin. 

In  the  initial  stage  of  eczema,  cleansing  with  alcohol  and  thorough 
powdering  with  the  stearate  of  zinc  is  sufficient.  Where  powdering  is 
indicated,  a  practical  application  is  zinc  oxide,  amyli  aa  20.0,  glycerini, 
aquae  dest.  aa  40.0. 

If  the  patient  is  first  presented  with  an  impetiginous  encrusted  eczema, 
as  is  usually  the  case,  it  is  necessary,  first,  to  remove  the  crusts  and  scabs. 
This  is  readily  accomplished  by  the  use  of  an  oil-cap  on  the  scalp  and  of  oiled 
bandages  on  the  face.  Olive  oil  is  usually  recommended,  but  the  ordinary 
cotton-seed  oil  is  satisfactory.  The  most  important  thing  is  that  it  be  cor- 
rectly applied.  A  piece  of  absorbent  cotton  or  a  strip  of  flannel  or,  pref- 
erably, sterile  gauze  is  saturated  with  oil  and  applied  over  the  crusts  to  be 
softened.  This  is  in  turn  covered  with  a  thin  layer  of  dry  cotton  and  with 
rubber  tissue  or  oil  silk.  The  head  is  covered  with  a  close-fitting  hood  and 
the  face  is  protected  with  a  gauze  mask.  The  oil  dressings  are  changed  each 
morning  and  evening.  Softening  of  the  crusts  proceeds  rapidly  and  then 
they  may  be  removed  readily  by  means  of  a  cotton-mounted  probe  or  a 
pair  of  blunt  tweezers. 

Some  authors  recommend  the  use  of  hydrogen  dioxide  (3  per  cent.),  for 
the  removal  and  deodorization  of  the  crusts,  while  others  prefer  the  following 
prescription:  1$.  Acidi  salicylici  2.0  (5ss);  olei  ricini,  40.0  (3x.);  olei  oliv. 
ad  100.0  (giiiss). 

Unguentum  diachylon  may  also  be  applied  thick,  it  will  not  only  soften 
and  remove  crusts  but  frequently  has  a  beneficial  effect  upon  the  eczema 
itself.  It  should  be  changed  twice  daily. 

When  the  eczema  has  been  cleaned  in  this  manner,  the  actual  treatment, 
after  the  following  described  methods,  is  to  be  inaugurated.  If  not  only 
the  cheeks  and  forehead,  but  also  the  mouth  and  chin  are  affected,  the 
use  of  a  so-called  eczema  mask  made  of  a  piece  of  sterile  absorbent  lint  or 
fine  sterilized  muslin  is  to  be  recommended.  The  lint  or  muslin  may  be 
laid  over  the  child's  face  and  the  eyes,  nose  and  mouth  marked  in  with  a 
pencil.  Holes  are  then  cut  in  the  marked  points  so  as  to  leave  eyes,  nose 
and  mouth  uncovered.  Tie-strings  may  be  sewn  to  the  mask  to  hold  it 
in  place. 

If  we  have  to  deal  with  a  weeping  eczema,  an  eczema  madidans,  very 
mild  measures  for  allaying  the  inflammation  must  first  be  employed  with 
the  intention  of  gradually  drying  up  the  secreting  surfaces. 

For  this  purpose,  dressings  moistened  with  a  solution  of  aluminum 
acetate  (1:10),  or  with  the  usual  boric  acid  solution  (4  per  cent.),  are  very 
helpful.  Later,  when  the  inflammation  has  subsided  and  the  secretion  has 
diminished  the  application  of  a  paste,  consisting  of  zinc  oxide,  talcum, 
lanolin,  and  petrolatum,  in  equal  parts,  will  serve  to  dry  up  the  secretion 
still  more.  Fox  paste  may  be  used  here  with  benefit.  A  moderate  amount 
51 


802  TEXT-BOOK  OF  PEDIATRICS 

(5-10  per  cent.),  of  the  triacetate  of  pyrogallol  (lenigallol),  added  to  this 
ointment  may  act  favorably.  The  itching  may  be  allayed  by  adding  1  to  5 
per  cent,  of  tumenol  or  naphthalene  (naphthalene,  adeps  lanse),  aa,  50.0 
(5xii),  acidi  borici,  10.0  (Siiss);  zinci  oxidi,  20.0  (5v).  If  the  secretion 
persists,  the  surface  should  be  painted  with  silver  nitrate  (1  per  cent.), 
once  or  twice  a  day;  or  an  application  of  gauze  moistened  with  a  silver 
solution  (1-10,000),  may  be  left  in  place  for  an  hour  or  so  with  good  effect. 
It  should  be  remembered  this  may  stain.  In  the  intervals  the  surfaces  may 
be  covered  with  powder  or  paste. 

When  the  secretion  has  ceased  and  the  eczematous  areas  appear  perfectly 
dry,  fatty  applications  are  indicated.  This  is  very  satisfactorily  carried 
out  by  equal  parts  of  zinc  oxide  and  olive  oil.  A  five  per  cent,  boric  acid 
ointment  may  be  used  instead. 

Emphasis  must  be  put  upon  the  fact,  however,  that  this  therapy, 
simple  and  rational  as  it  appears,  is  completely  successful  only  in  occasional 
cases.  In  hospitals,  with  skilled  attendants  and  unremitting  care,  the  results 
are  more  satisfactory  than  in  the  home.  Usually  a  point  is  reached  at 
which  improvement  ceases  and  even  where  exacerbations  may  occur. 
In  the  latter  event,  the  treatment  must  be  patiently  repeated  from  the 
beginning.  If,  however,  a  mere  arrest  of  improvement  occurs,  but  without 
any  acute  relapse,  the  eczema  may  be  said  to  have  taken  on  a  more  chronic 
character  and  treatment  with  some  tar  preparation  should  be  inaugurated, 
without  delay.  It  would  be  a  great  mistake  at  this  juncture  to  stop  exter- 
nal treatment.  The  entire  course  of  treatment  would  have  been  under- 
taken in  vain.  The  disease  process  still  persists  in  the  deeper  tissues;  the  skin 
is  usually  still  hyperemic;  is  densely  infiltrated;  and  the  itching  continues. 

The  following  will  serve  as  an  example  of  a  mild  tar  ointment,  suitable 
for  this  phase  of  the  disease:  1$:  Zinci  oxidi,  talci  aa  10.0  (Siiss);  petrolati 
20.0  (5v);  oleum  picis  liquidse  0.5  (minims  viii),  or  less.  Theanthrasol  zinc 
ointment,  anthrasol  1.0  (minims  xv):  unguenti  zinci  Wilsonii,  30.0  (5i)> 
may  be  substituted. 

Tar  is  also  the  most  useful  of  applications  in  the  disseminated  form  of 
chronic  eczema,  in  eczematous  placques  and,  therefore,  in  the  secondary 
form  of  the  disease.  Usually,  it  gives  results  rapidly,  while  other  remedies 
afford  no  improvement.  The  author  prefers  the  old  Wilkinson's  sulphur 
ointment.  This  may  be  accompanied  by  the  use  of  sulphur  baths  and  arsenic 
internally.  The  diachylon  ointment  prepared  according  to  the  old  formula, 
of  Hebra,  without  lavandula,  is  a  remedy  with  which  very  rapid  improve- 
ment takes  place,  excepting  with  very  sluggish,  old  eczematous  placques. 

Experience  has  shown  that  children  affected  with  eczema  sometimes  die 
suddenly  without  any  definite  or  apparent  cause.  We  speak,  in  fact,  of 
death  from  acute  eczema.  Pale  and  pasty  infants  are  especially  endangered, 
and  they  show  an  alarming  rate  of  mortality.  Should  such  a  misfortune 
occur  during  a  particularly  energetic  course  of  treatment,  the  popular 
tendency  is  to  lay  the  blame  to  the  effect  produced  in  "driving  in  the 
eruption."  The  writer  is  not  at  all  inclined  to  regard  such  forced  conclu- 
sions as  entirely  senseless  or  foolish,  since  we  know  nothing  of  the  real 


DISEASES  OF  THE  SKIN  803 

significance  of  eczema  as  a  natural  process  of  reaction.  The  fact  that  in 
these  cases  a  status  lymphaticus  is  often,  although  by  no  means  always, 
found  at  autopsy,  is  very  significant  indeed,  although  it  affords  no  satis- 
factory indication  of  any  relationship  between  the  eczema  death  and  the 
sudden  cessation  of  the  superficial  efflorescence.  It  must  be  remembered,  too 
that  sudden  death  may  happen  in  eczematous  children  from  extrinsic  causes 
altogether  unrelated  to  the  treatment  of  the  eczema.  It  has  been  known  to 
occur,  for  instance,  during  the  application  of  a  sweat  pack. 

URTICARIA 

Under  this  caption  are  grouped  a  number  of  diseases  which  are  rather 
variable  in  their  external  manifestations.  It  will  include  ordinary  urticaria, 
acute  circumscribed  edema  of  the  skin  (Quincke),  strophulus  and  prurigo, 
because,  from  the  first,  a  proper  emphasis  should  be  put  upon  their 
etiologic  relationship.  The  sufferer 
from  any  of  these  diseases  always  ex- 
hibits a  marked  and  excessive  varia- 
bility of  vascular  tone,  due  to  an 
increased  irritability  of  the  vasomotor 
mechanism, accompanied,  probably,  by 
abnormally  increased  permeability  of 
the  vessel  walls.  As  a  result,  the  pa- 
tient reacts  to  slight  stimuli  with  the 
appearance  of  true  urticarial  wheats 
—which  represent  clinically  the  funda- 
mental type 'of  lesion  of  this  large 
group  of  dermatoses. 

The  structural  feature  of  the  urti- 
carial wheal  is  found  in  a  marked 
injection  of  the  papillary  layer  and  the  FIG.  221.— Eczema  of  mouth  and  chin. 

i  •    i     •  •  ji       p   11  11  (Courtesy  of  Richard  L.  Sutton.) 

conum,  which  is  rapidly  followed  by 

serous  infiltration.  The  elevation  of  the  skin  resulting  from  this  appears 
red  (urticaria  rubra),  when  the  flush  of  the  injected  vessels  of  the  papillary 
layer  is  visible  through  the  epidermis;  it  appears  white  (urticaria  parcel- 
lanea),  when  an  extensive  serous  exudate  in  the  rete  forces  the  blood  out  of 
the  underlying  papillary  layer.  If  the  extravasated  serum  is  equally 
diffused  over  an  extensive  area  and  if  it  penetrates  also  to  the  deeper  subcu- 
taneous tissue,  the  entire  area  becomes  edematous,  the  feature  of  circum- 
scribed edema.  If  the  capillary  injection  is  more  intense  and  the  exudation 
is  very  slight,  a  flat,  very  slightly  raised  redness  appears  (erythema  urtica- 
tum).  If  the  centres  of  the  wheals  are  changed  by  induration,  to  an  inflam- 
matory papule,  strophulus  results  (urticaria  papulosa,  or  lichen  urticatus) 
which,  if  the  irritatitive  agent  persists,  may  go  on  to  the  development  of  a 
typical  and,  at  times,  a  very  obstinate  dermatosis  with  its  indurated 
papules,  characteristically  localized  on  the  extensor  surfaces  of  the  extrem- 
ities (prurigo). 

A  very  characteristic  clinical  sign  of  all  the  diseases  of  the  urticarial 


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group  is  the  itching.  Peculiar  as  it  is  in  a  degree  to  all  these  superficial 
eruptions  it  reaches  its  greatest  intensity  in  prurigo.  The  several  forms  of 
urticaria  recur  readily.  While,  however,  urticaria,  circumscribed  edema 
of  the  skin,  and  strophulus  are,  generally  speaking,  of  an  extremely  transi- 
tory nature,  true  prurigo  is  distinguished  by  its  eminently  chronic  course. 

From  the  case-history  we  very  frequently  learn  that  the  urticarial 
affection  is  familial;  that  brothers  and  sisters,  parents,  grandparents  or 
other  blood  relatives  have  suffered  or  still  suffer  from  similar  affections. 
Not  infrequently  the  condition  has  been  preceded,  in  early  life,  by  obstinate 
eczema  of  the  face  and  head.  Such  experiences  and  many  other  established 
facts  lead  us  to  suspect  the  existence  of  a  congenital  factor,  an  hereditary 

constitutional  anomaly  which  enters 
into  the  etiology  of  the  urticarial  der- 
matoses  and  expresses  itself  in  a 
marked  predisposition  to  angio-neu- 
rotic  inflammation. 

SIMPLE  URTICARIA 

Urticaria,  with  its  multiple  transi- 
tory eruption  of  wheals  is  a  very 
common  dermatosis  of  childhood. 
Sometimes  the  entire  body  is  thickly 
covered  by  the  eruption.  The  face 
may  be  greatly  distorted,  swollen, 
mottled  with  red  blotches,  cyanosed 
and  edematous. 

If  neighboring  wheals  coalesce,  large 
raised  plaques,  often  three  or  four 
inches  in  diameter,  are  formed,  which 
present  either  a  bright  red  or  a  more 
whitish  color. 

The  eruption  may  or  may  not  be 
accompanied  by  fever.  Usually  the 
urticaria  appears  unexpectedly  overnight  in  an  apparently  healthy  child 
and  disappears  with  equal  rapidity,  possibly  during  the  very  same  day.  In 
other  instances,  however,  the  rash  is  preceded  by  an  indefinite  prodromal 
period  of  several  days,  marked  by  vague  symptoms  of  malaise,  gastric  fever, 
etc.,  which  continue  until  a  general  urticaria,  with  intense  itching,  suddenly 
appears  and  clears  up  the  indefinite  disease-picture  at  once. 

Doubtless  there  is  an  urticaria  of  the  mucous  membranes  essentially 
similar  in  nature  to  the  external  cutaneous  disease.  This  runs  its  course 
with  severe  but  rapidly  passing  symptoms  of  irritation  and  swelling  in  the 
intestinal  tract,  the  pharynx,  the  larynx  and  bronchi.  A  typical  example 
of  this  peculiarity  is  seen  in  the  acute  asthmatic  attacks  suffered  by  certain 
predisposed  persons,  attacks  which  occur  suddenly  after  the  ingestion 
of  eggs,  lobster,  strawberries  or  some  other  particular  food,  and  are  fol- 
lowed immediately  by  the  customary  urticarial  eruption  on  the  skin. 


FIG.  222. — Anaphylactic  eczema.     (Courtesy 
of  Richard  L.  Sutton.) 


DISEASES  OF  THE  SKIN 


805 


We  have  no  definite  knowledge  of  the  actual  cause  of  urticaria.  Doubt- 
less stimuli  of  alimentary  toxic  origin,  and  from  colds,  exciting  the  urticarial 
skin  reaction  by  way  of  the  sympathetic  nervous  system,  play  an  important 
part.  Urticarial  serum  rashes  and  cow-pox  exanthemata  frequently 
appear  respectively  after  the  injection  of  a  foreign  serum  (antitoxin  serum), 
and  after  vaccination,  and  most  probably  may  be  attributed  to  the  action 
of  some  toxic  substance  liberated  by  the  combination  of  antigen  with  anti- 
body (the  so-called  anaphylatotoxin) .  To  what  extent  toxins  of  gastro- 
intestinal origin  are  connected  with 
the  causation  of  urticaria  is  an  open 
question.  Many  authors  consider 
them  of  great  etiologic  importance, 
especially  since  children  who  suffer 
with  urticaria  are  very  often  obsti- 
nately constipated. 

For  acute  general  urticaria,  rest  in 
bed  and  a  dose  of  castor  oil  should 
be  prescribed.  The  itching  may  be 
allayed  by  washing  the  skin  with  a 
weak  alcoholic  solution  of  menthol,  or 
with  vinegar  and  water  (equal  parts) 
and  by  the  subsequent  use  of  cooling 
ointments.  The  inauguration  of  a 
dietary  consisting  largely  of  vegeta- 
bles, as  great  a  reduction  of  milk  as 
possible  and  the  avoidance  of  eggs 
may  prevent  recurrences.  Baths  with 
sodium  bicarbonate,  salt,  borax,  am- 
monium chloride  one-half  ounce  to 
one  ounce  to  bath. 


FIG.  223. — Infantile     eczema.      (Courtesy      of 
Richard  L.  Sutton.) 


ACUTE  CIRCUMSCRIBED  EDEMA  OF  THE  SKIN  (GIANT  URTICARIA) 

This  condition  is  very  closely  related  to  simple  urticaria.  In  rare  cases 
it  occurs  as  a  distinct  disease  unaccompanied  by  urticaria.  In  such  an 
instance  it  is  of  a  typical  familiar  character.  The  favorite  site  of  this 
acute  edema  is  on  the  face  and  particularly  in  the  loose  connective  tissue  of 
the  eyelids.  Usually  the  symptoms  completely  disappear  in  a  few  hours. 
Coincident  edema  of  the  pharynx  or  larynx  may  cause  serious  difficulty  in 
swallowing  and  breathing. 

Some  authors  claim  to  have  obtained  rapid  relief  with  cold  sitz-baths  or 
ice-packs. 

STROPHULUS 

In  infants  and  young  children  urticaria  very  frequently  takes  a  papular 
form  (strophulus,  lichen  urticatus,  urticaria  papulosa).  If  opportunity 
is  given  to  observe  an  early  case,  one  sees  clearly  how,  at  the  centre  of  the 
wheal  or  in  the  smaller  urticarial  macules,  hard  globular  papules  of  dark  red 


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color,  begin  to  arise.  After  a  day  or  two  the  redness  and  the  urticarial  base 
disappears,  the  papules  become  paler  and  clearer  and  persist,  then  unchanged 
for  a  time,  as  small  waxy  hard  hemispheral  papules.  At  times  a  small 
vesicle  appears  at  the  apex,  which  may  under  certain  circumstances 
become  purulent  (strophulus  vesiculosus  or  impetiginosus) .  At  this  stage, 


FIG.  224. — Lichen  urticatus  or  strophulus.      Arranged  in  groups. 
(Dresden  Infant's  Home,  Prof.  Schlossmann.) 

the  urticarial  nature  of  the  malady  is  hardly  determinable  unless,  as  fre- 
quently happens,  new  urticarial  wheals  appear  on  other  areas  of  the  skin. 

The  outbreak  of  strophulus  is  rarely  general.  Usually,  the  exanthem  is 
confined  to  certain  areas  of  the  body.  Its  fairly  dense  grouping  on  the  arms 
and  legs  and  especially  in  the  region  of  the  joints  is  quite  characteristic. 
Sometimes  the  strophular  eruption  follows  quite  closely  the  course  of  an 
intercostal  nerve.  The  intense  itching  which  attends  the  eruption  is  typical. 
As  a  result  the  strophular  papules  are  often  severely  scratched  and  covered 
with  small  blood  crusts. 

What  has  been  said  of  the  etiology  and  treatment  of  urticaria  is  also 


DISEASES  OF  THE  SKIN  807 

true,  in  a  general  way,  of  this  condition.  The  frequency  of  occurrence  of  the 
disease  in  this  form  in  very  young  children  may  be  dependent  upon  struc- 
tural peculiarities  of  the  skin.  This  may  readily  explain  the  noticeable 
fact  that  a  post-vaccination  exanthem,  occurring  during  the  first  year  of  life, 
very  frequently  takes  on  the  form  of  strophulus. 

The  treatment  of  strophulus  must  be  chiefly  dietetic.  In  infants,  one 
should  radically  reduce  the  quantity  of  milk  as  recommended  in  eczema.  In 
children  past  infancy  all  milk  and  eggs  should  be  absolutely  prohibited. 
Good  results  have  been  gained,  in  many  cases,  by  following  this  principle 
of  treatment. 

PRURIGO 

The  term  prurigo  is  applied  to  an  intensely  itching,  chronic,  papular 
eruption,  which  localizes  itself  in  typical  cases,  chiefly  on  the  extensor  sur- 
faces of  the  extremities.  The  primary  lesion  of  the  exanthem  occurs  as  the 
so-called  prurigo  papules.  These  are  hard  elevations  in  the  upper  layers  of 
the  skin,  varying  from  a  pinhead  to  a  hemp-seed  in  size,  of  either  a  pale  red 
or  a  whitish  color.  Usually  as  the  result  of  scratching,  they  show  small 
blood  crusts  at  their  apices.  If  the  hand  is  passed  over  the  surface  of  the 
affected  skin,  a  feeling  similar  to  that  of  contact  with  a  fine  grater  is  noted. 

The  clinical  relationship  of  prurigo  to  urticaria  is  shown  by  the  fact  that 
the  former  almost  always  arises  from  the  previously  described  lichen 
urticatus.  Strophulus,  or  lichen  urticatus,  indeed,  may  be  looked  upon  as 
an  earlier  stage  of  an  ensuing  prurigo.  Furthermore,  one  frequently  sees 
upon  the  site  of  an  advanced  prurigo  repetitional  crops  of  urticarial  wheals 
and  lichen  papules  appearing  spontaneously  or  as  a  result  of  scratching. 

The  onset  of  a  prurigo  may  always  be  traced  back  to  early  childhood. 
The  transitory  strophulus  shows  a  tendency  to  persist,  and  the  temporary 
angioneurosis  passes  into  an  essential  dermatosis.  While  the  earlier 
eruption  is  diffused  over  the  entire  body,  in  this  chronic  stage  with  the 
appearance  of  the  small  inflamed  prurigo  papules,  it  is  peculiarly  confined 
to  the  extensor  surfaces,  particularly  of  the  legs,  where  it  persists  unchanged 
for  a  long  time. 

The  nodules,  frequently  scratched  and  secondarily  infected,  involve  the 
regional  lymph  nodes,  which  often  become  greatly  enlarged  and  form  the 
so-called  prurigo  bubos.  These  may  be  easily  palpable  and  even  visible  in 
the  groin.  The  coincident  appearance  of  acute  hemorrhagic  nephritis  is 
not  at  all  uncommon. 

In  childhood  we  usually  meet  with  a  mild  form  of  prurigo,  the  so-called 
prurigo  simplex  or  mitis,  which  is  fairly  amenable  to  external  treatment. 
The  unconquerable,  troublesome  and  much  dreaded  prurigo  f  erox  of  Hebra, 
appears,  probably,  only  at  a  later  period. 

The  causes  which  underlie  prurigo,  are,  of  course,  identical  with  those 
which  produce  urticaria.  An  important  causative  influence  is  undoubtedly 
to  be  found  in  inadequate  care;  since,  otherwise  it  would  be  hard  to  under- 


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stand  why  so  many  chronic  cases  recover  completely  with  no  other  treat- 
ment than  that  of  complete  rest  in  a  clean  hospital  bed. 

External  treatment  is  directed  chiefly  to  the  maceration  and  softening 
of  the  indurated  epidermis.  Sweat-producing  packs  are  extremely  useful 
and  applied  locally  to  the  legs  and  arms  may  be  continued  for  several  hours 
at  a  time  during  a  period  of  four  days.  Cloths,  moistened  in  a  warm 


FIG.  225. — Prurigo.      Area  of  predilection  of  the  numerous 
scratched  nodules  on  the  extensor  surfaces  of  the  extremities. 


solution  of  salicylic  acid  (5i  to  Oii),  and  covered  with  flannel  may  be 
satisfactorily  used  for  this  purpose.  During  the  intervals  between  the 
warm  fomentations,  the  affected  skin  areas  should  be  protected  with  a 
bland  ointment. 

The  highly  praised  treatment  by  intestinal  disinfection  can  hardly  be 
considered  efficacious.  If  it  is  considered  possible  to  improve  the  general 
condition  of  the  patient  by  the  use  of  iron  preparations  or  the  so-called 
roborants,  and  if  one  believes  that  he  may  "correct  metabolic  errors"  by 
the  use  of  these  remedies,  they  may  be  tried. 


809 


MULTIPLE  ERYTHEMA 

(ERYTHEMA  MULTIFORME) 

A  large  variety  of  cutaneous  reactions  are  classed  in  the  group  of 
erythemata.  According  to  their  morphologic  characteristics  and  the  stage  of 
development  in  which  they  appear,  they  are  termed  erythema  papulatum, 
tuberculatum,  hemorrhagicum,  contusiforma,  marginatum,  annulare,  vesic- 
ulosum  and  iris.  Erythema  nodosum,  which  is  often  thought  to  require  a 
special  classification  is  also  very  closely  related  to  this  group  of  dermatoses. 

Pathologically,  an  inflammatory  process  is  found  in  all  these  cases.  This 
constitutes  a  true  dermatitis,  occurring  in  foci  in  the  skin  and  the  subcu- 
taneous tissues.  In  their  later 
course,  these  foci  may  form  fairly 
circumscribed  papular  or  large  nod- 
ular exudations.  The  old  general 
name  erythema  is,  therefore,  not 
very  appropriate,  since  the  disease 
is  really  more  than  a  diffuse  red- 
dening of  the  skin  depending  upon 
a  pure  hyperemia.  For  this  reason, 
these  erythemata,  since  the  time  of 
Hebra,  have  been  differentiated 
from  simple  erythema  by  empha- 
sizing the  exudative  process  they 
involve  and  by  distinguishing  the 
group  as  erythema  exudativum  mult- 
iforme.  From  the  purely  clinical 
standpoint,  many  subdivisions  of 
the  erythemata  may  be  made  upon 
the  basis  of  the  numerous  gross 
variations.  In  the  first  place,  one 
may  distinguish  between  the  more 
diffuse  general  erythemata  and 
the  circumscribed  localized  forms. 
The  former  may  resemble  measles  or  rubella,  or  may  even  simulate  the 
picture  of  a  scarlet  fever  eruption.  The  careful  observer,  however,  will 
usually  note  the  more  nodular  or  finely  papular  character  of  the  individ- 
ual lesions  of  the  erythemata. 

In  the  case  of  the  localized  erythemata,  we  again  meet  at  least  two  prin- 
cipal types:  (1)  A  form  with  an  unmistakable  tendency  to  superficial 
spread  of  the  erythema;  and  (2)  a  form  essentially  circumscribed,  in  which 
discrete,  nodular  infiltration  foci,  varying  from  a  hazel-nut  to  a  pigeon's 
egg  in  size,  occur  in  small  distinctly  limited  areas  (erythema  nodosum). 
Especially  remarkable  is  the  typical  localization  of  both  of  these  erythemas 
on  the  extensor  surfaces  of  the  extremities;  in  a  general  way,  the  superficial 
eruption  on  the  upper  extremities  particularly  around  the  wrist  and  elbow 
joints,  and  the  nodular  eruption  on  the  extensors  of  the  lower  extremities, 


FIG.  226. — Erythema     multiforme. 
Richard  L.  Sutton.) 


(Courtesy 


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especially  over  the  edge  of  the  tibia.  Both  forms  show  a  certain  tendency  to 
small  hemorrhages,  but  this  is  more  characteristic  of  the  nodular  than  of  the 
superficial  type.  If  the  nodules  over  the  tibia  are  discolored  by  the  extrav- 
asated  hemoglobin,  obviously  they  may  be  designated  also  as  contusi- 
form  erythema,  according  to  Hebra. 

Presumably  all  these  erythemata  have  a  common  pathologic  basis  in 
some  noxious  agent  serving  as  a  stimulus  within  the  organism  provocative 
of  toxic  reaction.  Accordingly  it  is  not  surprising  that  the  eruption  is  often 
accompanied  by  a  more  or  less  severe  malaise  and  may  at  times  be  ushered 
in  or  accompanied  by  high  febrile  disturbance. 

The  noxious  agent  itself  may  be  found : 

a.  In  the  toxic  action  of  bacteria  and  bacterial  products,  e.  g.,  in  septic 
erythema,  erythema  in  the  course  of  such  diseases  as  cerebrospinal  men- 
ingitis, rheumatism,  and  influenza. 

6.  In  the  toxic  action  incident  to  the  binding  of  specific  antigens  and 
antibodies;  e.  g.,  the  erythema  of  serum  disease,  of  post-vaccination,  of 
active  tuberculosis,  or  as  a  feature  of  the  tuberculin  reaction;  erythema 
during  measles  and  following  scarlet  fever. 

c.  In  the  action  of  a  medicinal  agent  against  which  the  patient  has  an 
idiosyncrasy,  a  so-called  drug  eruption. 

It  should  be  noted  that  the  type  of  cutaneous  reaction  is  by  no  means 
specific  or  constant.  One  and  the  same  noxious  agent  may  now  produce 
one  form  of  erythema  and  again  a  different  type.  Then,  for  instance,  one 
may  see,  as  a  result  of  the  percutaneous  application  of  tuberculin,  at  dif- 
ferent times,  a  general  exanthem  resembling  scarlet  fever  or  measles,  a 
localized  erythema  of  the  flat  superficial  type  or  the  nodular  form,  which, 
in  one  case  recorded,  was  a  typical  erythema  nodosum.  Close  relation 
apparently  exists  between  erythema  nodosum  and  tuberculosis.  Children 
suffering  with  the  former  disease  usually  show  an  intense  positive  reaction 
to  tuberculin ;  a  behavior,  however,  which  is  not  constant. 

The  relationship  of  erythema  multiforme,  especially  in  its  localized 
forms,  to  rheumatic  conditions  is  very  distinct,  but  is  by  no  means  under- 
stood. Joint  affections  and  muscular  pains  are  not  infrequently  combined 
with  erythema.  Cases  are  common  in  the  experience  of  every  clinician 
which  present,  on  first  acquaintance,  some  form  of  erythema  and  reappear 
after  a  few  years  with  peliosis  rheumatica,  with  chorea,  or  with  a  systolic 
murmur  audible  at  the  apex.  If  the  signs  of  erythema  multiforme  appear 
in  the  skin  over  an  affected  joint  during  the  course  of  acute  articular  rheu- 
matism the  pain  often  disappears  very  suddenly. 

In  their  differential  diagnosis  the  infectious  erythemata,  the  so-called 
fourth  and  fifth  diseases  present  special  difficulties,  which  at  times,  appear 
insurmountable  if  one  cannot  locate  the  source  of  infection  or  if  they  do  not 
occur  in  the  course  of  an  epidemic. 

Cool  fomentations  of  a  solution  of  aluminum  acetate  have  a  favorable 
affect  upon  the  local  inflammation.  Acetyl-salicylic  acid  should  be  given 
in  event  of  a  rheumatic  relation  in  the  localized  erythema. 


DISEASES  OF  THE  SKIN  811 

IMPETIGO 

This  group  includes  impetigo  contagiosa,  pemphigus  neonatorum,  and 
dermatitis  exf oliativa,  all  of  which  are  contagious  dermatoses  caused  by  the 
pyogenous,  staphylo-  and  streptococci.  Their  grouping  is  dependent  upon 
their  etiology. 

Especially  instructive  are  the  comparisons  to  be  drawn  between  the 
results  of  pemphigus  infection  in  infants  producing  a  typical  impetigo 
in  older  children  or  adults.  The  evident  factor  of  difference  by  which  one 
and  the  same  infection  will,  in  the  young  infant,  produce  large  pemphigus 
blebs  or  even  extensive  exfoliation  of  the  epidermis  (dermatitis  exf  oliativa), 
while  in  later  childhood  it  causes  only  small  impetiginous  pustules,  lies  in 
the  anatomic  structure  of  the  skin.  In  the  delicate  skin  of  the  new-born  an 
extensive  separation  of  the  thin  stratum  corneum  occurs  very  readily;  in 
the  older  and  firmer  cutaneous  structures,  on  the  contrary,  the  same  exuda- 
tive process  loosens  only  a  small  area.  Furthermore  one  sometimes  sees 
true,  small  impetiginous  pustules  in  the  new-born,  which  show  no  tendency 
to  superficial  spread  and,  strangely  enough,  are  without  tendency  to  incrus- 
tation (impetigo  bullosa). 

IMPETIGO  CONTAGIOSA 

The  primary  lesion  in  impetigo  contagiosa  is  the  characteristic  pustule. 
This  is,  at  first,  a  small  but  rapidly  growing  purulent  vesicle  surrounded  by 
a  small  areola  of  inflammation.  The  pustules  soon  rupture,  dry,  and  are  then 
covered  with  light  yellow  or  brownish  crusts.  On  account  of  the  conta- 
giousness of  the  process,  the  lesions  of  impetigo  usually  soon  become 
confluent.  On  the  face  and  around  the  mouth  and  nose  they  form  wreath- 
like  figures,  or  on  the  scalp,  a  dense  encrusted  mass.  As  a  result  of 
scratching,  the  pyogenic  organisms  are  often  carried  to  distant  parts  of 
the  body  and  new  crops  of  impetiginous  pustules  appear  on  the  hands,  arms, 
legs  or  trunk.  The  intra-scapular  space  alone  is  hardly  ever  infected  since 
the  child  cannot  reach  it  with  its  finger-nails. 

It  is  a  remarkable  fact,  that  in  spite  of  the  demonstrated  contagiousness 
of  impetigo,  and  with  exactly  the  same  chance  of  infection,  not  all,  but  only 
a  certain  group  of  children  are  affected  with  the  disease.  It  is  probable  that 
the  germs  of  impetigo  can  invade  only  those  skins  which  react  to  the  irri- 
tation of  the  infective  organism  by  a  local  inflammation,  to  which  reaction 
certain  individuals  are  especially  and  naturally  predisposed.  The  pyogenic 
cocci  thrive  in  the  products  of  this  inflammatory  process  and  pustules  result. 

If  the  impetigo  appears  as  an  independent  primary  affection,  the  skin 
around  the  pustule  shows  little  or  no  change.  This  gives  the  round  crusts 
the  appearance  of  being  stuck  on  the  skin.  In  secondary  impetigo  an 
entirely  different  condition  is  found,  which  often  results  from  scratching 
or  uncleanliness  on  a  skin  soil  previously  affected  by  eczema,  urticaria, 
or  strophulus. 

A  peculiar  form  of  contagious  impetigo  is  the  ordinary  ecthyma,  which, 
contrasted  with  the  conditions  just  described,  seems  to  arise  from  the 


812 


TEXT-BOOK  OF  PEDIATRICS 


deeper  layers  of  the  skin.  A  hard,  tensely  infiltrated  inflammatory  nodule 
of  a  bright  red  color  appears  on  the  skin.  From  this  the  pustule  develops 
and  usually  passes  through  the  same  stages  as  an  ordinary  impetigo.  The 

pustules  of  ecthyma  show  no 
tendency  to  group,  but  are 
always  discrete.  They  are  most 
frequently  seen  on  the  extensor 
surfaces  of  the  lower  extremities 
and  on  the  nates.  This  form  of 
eruption  is  most  frequently  seen 
following  scabies.  If  scratched, 
it  leaves  distinct  scars  which 
persist  much  longer  than  the  pale 
red  spots  following  impetigo. 

In  the  treatment  of  impetigo 
excellent  results  are  obtained 
by  the  use  of  oil-packs  to  soften 
the  crusts  followed  by  applica- 
tions of  the  unguentum  hydrar- 
gyrum ammoniatum  (2  per 
cent.) .  If  the  pustules  of  impet- 
igo are  scattered  over  the  body, 
the  individual  lesions  may  be 
covered  with  adhesive  plaster 
containing  ammoniated  mer- 
cury. Under  proper  treatment  impetigo  disappears  in  a  few  days.  Ecthyma 
is  much  more  obstinate  and  the  application  to  it  of  ammoniated  mercury 
ointment  should  be  preceded  by  the  use  of  dressings  moistened  with  a  solu- 
tion of  aluminum  acetate. 

PEMPHIGUS  NEONATORUM 

This  is  a  very  characteristic  skin  disease  of  the  new-born,  accurately 


Fia.  227. — Impetigo  coutagiosa.  (Courtesy  of  H.  H.  Hazen.) 


FIG.  228. — Pemphigus  neonatorum.     Intact  and  ruptured  vesicles. 
Favorable  termination. 

described  as  early  as  the  beginning  of  the  seventeenth  century.    It  consists 


DISEASES  OF  THE  SKIN 


813 


in  the  appearance  of  discrete  vesicles,  varying  in  diameter  from  one  to 
three  centimeters,  filled  with  a  slightly  cloudy  fluid  and  resting  upon  a 
normal  mound  or  very  slightly  inflamed  base.  The  epidermis  over  the 
smaller  vesicles  is  tense,  while  that  over  the  large  ones  is  loose  and  rather 
redundant.  Frequently  the  vesicles  have  ruptured  and  are  empty  when  the 
patient  is  first  seen.  There  remain  red,  circular  or  oval  areas  which  are  still 
moist  or  have  dried  up  and  are  surrounded  with  the  delicate  whitish  shreds 
of  the  ruptured  horny  layer. 

This  eruption  of  superficial  vesicles  will  occur  in  children  who  are  in 
perfectly  good  health.  Any  constitutional  symptoms  are  of  secondary  na- 
ture or  are  unrelated  to  the  skin  condition. 

Therapy. — Daily  baths  of  a  weak  potassium  permanganate  solution 
should  be  followed  by  the  free  use  of  such  an  antiseptic  drying  powder  as 
stearate  of  zinc. 

DERMATITIS  EXFOLIATIVA 

Under  this  name  von  Ritter  (1870)  described  a  very  peculiar  exudative 
dermatosis  which  occurred  in  young  infants  and  lead  to  extensive  exfolia- 
tion of  the  epidermis.  The  disease  appeared 
at  that  time  in  epidemic  form  in  the  Found- 
ling's  Institute  at  Prague. 

This  comparatively  rare  dermatosis 
may  attack  children  in  the  very  first  week 
of  life.  It  begins  with  a  general  reddening 
of  the  skin,  first  appearing  on  the  face  and 
especially  around  the  mouth  and  often 
spreading  rapidly  over  the  entire  body. 
It  is  always  accompanied  by  the  eruption 
of  numerous  small  discrete  vesicles.  These 
areas  of  the  epidermis  then  become  under- 
mined by  a  widespread  edema  which  sepa- 
rates the  superficial  tissues  from  the  corium, 
so  that  the  former  may  be  easily  moved 
back  and  forth  with  the  finger.  The  deli- 
cate outer  covering  is  very  easily  broken, 
the  horny  layer  is  peeled  off  in  large  shreds 
and  the  inflamed  rete  lies  bare. 

On  the  face,  the  edematous  infiltration 
of  the  skin  is  primary.  Radial  fissures  and 
deep'rhagades  are  formed,  especially  around 
the  mouth,  presenting  a  picture  which 
closely  resembles  that  of  lues,  saving  that 
it  is  much  more  pronounced  and  grotesque. 
A  similar  process  may  develop,  at  the  same 
time,  on  the  mucous  membranes,  the  conjunctiva,  in  the  mouth  and  in  the 
anterior  nares. 


f 


FIG.  229. — Exfoliative  dermatitis  (Hitter's 
disease).     Fourteen-day-old  infant. 


814  TEXT-BOOK  OF  PEDIATRICS 

It  is  really  remarkable  that  delicate  babes  are  not  more  seriously  affected 
from  the  beginning  by  this  terrible  dermatosis.  In  uncomplicated  cases 
the  course  is  entirely  without  fever  and  the  nutritional  functions  are  undis- 
turbed for  some  time.  Nevertheless,  the  prognosis,  especially  in  artificially- 
fed  children,  is  grave,  since  septicemia  may  very  readily  develop  upon  this 
specially  favorable  soil  and  may  change  the  outlook  very  suddenly.  Accord- 
ing to  von  Ritter,  the  mortality  is  fifty  per  cent. 

Therapy. — Fomentations  of  dilute  aluminum  acetate  solution  are  lightly 
applied  to  the  highly  inflamed  parts;  or  these  may  be  painted  with  solution 
of  silver  nitrate  (3  per  cent.).  One  or  two  baths  in  a  solution  of  tannin  may 
be  given  daily.  After  thorough  drying,  the  entire  body  is  to  be  covered 
with  dusting  powder. 

FURUNCULOSIS 

Furunculosis  of  the  cellular  tissue  occurring  in  older  children  does  not 
differ,  either  in  nature  or  treatment,  from  the  same  process  in  the  adult.  In 
infancy,  however,  we  often  see  a  very  characteristic  type  of  furuncle  in  the 
skin,  presenting,  in  fact,  a  skin  lesion  peculiar  to  this  age.  These  skin 
furuncles  of  infancy  are  superficial  to  the  cellular  tissue  and  are  always 
multiple.  Multiple  furunculosis  of  the  skin  and  multiple  cutaneous  ab- 
scesses, in  infancy,  are  interchangeable  terms. 

Furuncles  do  not  occur  in  healthy  infants.  Their  presence  is  always  a 
sign  of  illness  and  conclusive  evidence  that  the  natural  resistance  is  mark- 
edly below  par.  The  condition  is  frequently  resultant  from  severe  disturb- 
ances of  nutrition. 

An  enormous  number  of  abscesses  may  develop.  In  some  instances  a 
hundred  or  more  have  been  seen.  At  first  they  may  be  no  larger  than  a 
pea;  persisting,  there  may  be  some  as  large  as,  or  even  larger  than,  a  walnut. 
In  this  event  they  are  apt  to  become  soft  and  flabby.  If  they  are  punctured, 
pus  and  blood  are  often  forcibly  evacuated.  They  are  commonly  known 
as  boils. 

Clinically,  two  types  may  readily  be  distinguished:  (1)  The  most 
common  seat  of  the  furuncles  is  over  the  occiput,  the  neck  and  the  back; 
that  is  on  those  parts  of  the  body  which  are  exposed  to  friction  and  perspire 
more  freely  than  others.  At  first,  numerous  small  pustules  appear,  cor- 
responding in  site  to  the  orifices  of  the  sweat  glands  (Lewandowski  's  peri- 
poritis).  From  these  pustules,  abscesses  later  develop.  Obviously  an 
ectogenous  mode  of  infection  plays  a  most  important  part  in  such  a  process. 
At  the  same  time  the  child  so  affected  often  suffers  from  disturbances  of 
nutrition,  although  this  is  by  no  means  invariably  true.  (2)  In  the  other 
form,  the  furuncles  are  quite  as  numerous,  but  on  the  breast,  the  nates  and 
the  extremities.  No  special  area  of  predilection  is  determinable  however. 
Oftentimes  the  entire  body  is  literally  covered  with  boils.  The  resulting 
abscesses  enlarge  with  great  rapidity  and  are  of  a  livid  color.  The  sufferers 
from  this  dermatosis  are,  without  exception,  pale  emaciated  run-down 
infants  who  show  very  distinctly  the  clinical  evidences  of  atrophy.  The 
appearance  of  successive  crops  of  furuncles  can  hardly  be  avoided  in  chil- 


DISEASES  OF  THE  SKIN  815 

dren  of  this  type  even  though  the  skin  be  most  carefully  protected  against 
infection.  Such  a  furunculosis  probably  springs  from  an  endo-  hematogenous 
source.  This  does  not  imply  the  existence  of  a  septicemia,  since  a  few  pyo- 
genic  organisms  in  the  circulating  blood  can  easily  be  demonstrated  in  many 
cachectic  infants  with  poor  resistance,  who  are  by  no  means  in  a  condition, 
clinically,  of  sepsis. 

The  treatment  requires  great  patience.  Each  furuncle  is  to  be  opened 
with  a  sharp  scalpel  and  the  exuding  pus  removed  immediately  with  a 
pledget  of  cotton,  moistened  in  mercuric  chloride  solution.  Large  fur- 
uncles should  be  incised  while  the  patient  is  in  a  warm  sublimate  bath. 
Following  this  the  skin  is  freely  treated  with  a  bland  antiseptic  powder. 
It  is  best  to  lay  the  child  on  a  bed  of  zinc  powder  or  bran.  Moist  packs  and 


FIG.  230. — Multiple  skin  abscesses  in  an  infant. 

ointments  are  not  indicated  and  are  not  desirable  even  when  combined 
with  an  antiseptic.  Recently,  cauterization  of  the  centre  of  the  furuncle 
with  a  sharp  cautery  point,  has  given  good  results  in  several  cases  of  the 
first  group.  Excellent  results  are  obtained  with  autogenous  vaccines  and 
even  stock  vaccines  may  be  useful. 

PARASITIC  SKIN  DISEASES 
PEDICULOSIS 

With  inadequate  care,  the  head  louse  (pediculus  capitus),  a  very  com- 
mon inhabitant  of  the  hair  of  children  of  the  less  educated  classes,  may  lead 
to  a  dermatosis  of  an  impetiginous  character,  which,  on  account  of  its 
etiology,  is  known  as  pediculosis.  The  scalp  itches  intensely,  its  epidermis 
desquamates  freely,  and  it  is  covered,  here  and  there,  with  large  thick  and 
rather  firmly  adherent  crusts,  with  which  the  hair  is  more  or  less  matted. 
Eczematous  papules  forming,  when  scratched,  fresh  pustules  are  often  found 


816  TEXT-BOOK  OF  PEDIATRICS 

at  or  near  the  hair-line.  Especially  characteristic  is  a  secondary  eczema 
at  the  nape  of  the  neck  which,  incident  to  scratching,  extends  down  between 
the  scapulae  in  a  narrow  streak.  If  this  sign  shows  itself  we  may  be  very 
certain  that  the  head  louse  is  or  has  been  present.  Close  inspection  will 
reveal  numerous  nits  if  not  the  living  lice. 

The  treatment  should  be  directed,  first,  against  the  living  parasites; 
second,  against  the  resulting  skin  conditions;  and,  lastly,  against  the  nits. 
The  first  objective  may  be  reached  by  washing  and  then  soaking  the  hair 
with  equal  parts  of  kerosene  and  olive  oil,  after  which  the  entire  head  is 
firmly  covered  with  a  towel  left  in  place  overnight.  The  hair  is  washed  again 
in  the  morning. 

The  second  step  in  the  treatment  consists  in  removing  the  softened 
crusts  and  treating  their  bases  with  an  ointment  of  ammoniated  mercury. 
The  eczema  will  disappear  spontaneously  after  the  parasites  have  been 
destroyed  and  the  itching  has  ceased.  Later,  if  necessary,  pastes  and  pow- 
ders may  be  used. 

The  third  requirement,  the  removal  of  the  nits  may  be  accomplished  by 
the  application  of  vinegar  or  a  1  per  cent,  solution  of  acetic  acid  to  dis- 
solve the  chitin,  after  which  the  hair  is  repeatedly  combed  with  a  fine- 
tooth  comb. 

Shaving  or  clipping  the  hair  makes  the  treatment  much  easier,  of  course, 
but  can  hardly  be  done  with  girls,  excepting  in  extreme  cases.  It  may  be 
necessary  to  remove  the  hair  from  the  larger  pustular  areas. 

SCABIES 

The  etiologic  factor  in  scabies  is  the  itch-mite  (Sarcoptes  hominis  or 
Acarus  scabiei),  the  burrowing  of  which  into  the  skin  causes  an  extremely 
annoying  affliction  commonly  known  as  the  itch.  Here,  again,  the  most 
important  features  of  the  clinical  picture  are  the  secondary  manifestations 
which  often  appear  over  the  entire  skin  in  consequence  of  the  intense 
itching  and  the  severe  scratching.  The  itching  becomes  almost  unbearable, 
especially  at  night  when  the  body  is  thoroughly  warmed.  The  numerous 
bloody  crusts  and  streaks  which  appear  prominently  on  the  skin  of  the  back 
and  chest,  are  valuable  diagnostic  signs  of  the  itch.  They  show  plainly  how 
recklessly  the  patient  scratches  the  skin  in  order  to  alleviate  the  unbearable 
itching.  This  practice  fully  accounts  for  the  manifold  secondary  skin 
symptoms  which  appear.  Among  these  symptoms,  we  note  a  reflex  eczema 
(see  page  791),  urticaria  and  prurigo,  numerous  papules  and  suppurating 
vesicles,  impetigo  and  ecthyma,  all  of  which,  following  in  the  wake  of 
scabies,  are  essential  parts  of  the  clinical  picture.  The  fact  that  these 
manifestations  are  more  numerous  and  more  distinct  than  in  the  scabies  of 
later  years,  is  due  to  the  tenderness  and  high  fluid  content  of  the  child 's  skin. 

In  the  examination  of  a  case  of  scabies  a  definite  conclusion  depends 
upon  the  discovery  of  the  parasite  itself;  but  even  without  this  positive 
evidence  or  even  without  the  demonstration  of  the  typical  burrows  made 
by  the  organism  we  cannot  err  in  making  the  diagnosis  of  scabies  if  the  con- 


DISEASES  OF  THE  SKIN  817 

ditions  described  are  found.    This  is  best  shown  by  the  favorable  results  of 
proper  treatment. 

The  burrows  are  most  frequently  formed  on  the  hands  and  feet  and 
especially  upon  the  inner  surface  of  the  wrist,  the  inner  edges  of  the  fingers 
and  on  the  dorsum  of  the  foot.  They  may  occur,  also  in  other  parts  of  the 
body  and  are  often  seen  in  the  bend  of  the  elbow,  the  popliteal  area  and  even 
in  the  tough  epidermis  of  the  palms  of  the  hands  and  the  soles  of  the  feet 
(see  Figures  231-232).  The  burrows  are  either  straight  or  slightly  curved 
and  are  from  one-half  to  one  centimeter  long  and  from  one-half  to  one 
millimeter  wide.  The  termination  of  a  burrow  is  distinguished  by  the  fact 
that  a  small  whitish  raised  point  is  usually  found  there.  This  is  the  parasite. 
In  order  to  demonstrate  the  mite,  this  spot  is  opened  up  with  the  point  of  a 


Fio.  231.  —  Scabies.    (Courtesy  of  Richard  L.  Sutton.) 

sharp  knife.  It  is  not  necessary  to  open  the  entire  duct,  since  this  usually 
causes  irritation. 

Various  antiparasitics  have  been  recommended  for  the  treatment  of 
scabies.  A  combination  of  sulphur,  tar,  and  soap  has  gained  great  popularity. 

We  have  used,  for  years,  Wilkinson's  ointment  as  modified  by  Hebra, 
as  follows: 


R     Calcii  carbonatis  precipitati  10.0 

Sulphuris  sublimati 

Oleii  cadini  aa  15.0  (5ss) 

Saponis  viridis 

Adepis  tanae  aa  30.0  (Ji) 

M.  et  fiat  in  unguentum. 

The  method  of  use  is  as  follows:  In  the  evening,  the  entire  body  is  to 
be  covered  with  green  soap,  thoroughly  rubbed  in,  after  which  the  patient  is 
given  a  warm  bath  and  rubbed  dry.  Then  the  ointment  prescribed  is 
applied  and  rubbed  in  thoroughly.  The  hands  and  feet  should  receive 
special  attention. 
52 


818  TEXT-BOOK  OF  PEDIATRICS 

On  the  following  day,  the  ointment  is  repeated  in  the  morning.  The 
child  is  kept  in  bed  and  a  further  inunction  is  given  at  night. 

On  the  second  day,  in  the  morning,  the  remains  of  the  ointment  are 
removed  with  absorbent  cotton  and  oil,  after  which  the  entire  body  is  pow- 
dered with  zinc  oxide  talcum.  In  the  evening  a  warm  bath  is  given  and  a 
complete  change  of  clothing  and  bedclothes  is  provided. 

It  is  really  remarkable  how  well  the  acute  and  maltreated  eczema  of 
scabies  responds  to  this  severe  treatment  as  compared  to  eczemata  of  other 
causation.  Irritations  are  comparatively  uncommon.  If  they  do  occur  the 
inflamed  skin  must  be  furthur  treated  with  zinc  ointment  and  powder. 


FIG.  232. — Scabies,  pustular  exanthem. 

In  infancy,  milder  ointments,  e.  g.,  a  mixture  of  equal  parts  of  balsam 
peru  and  olive  oil  or  styrax,  are  usually  employed.  The  treatment  must, 
be  continued,  however,  for  several  days. 

TUBERCULOSIS 

The  child 's  skin  is  probably  very  rarely  the  primary  seat  of  tubercu- 
losis. This  might  be  true  in  lupus  more  than  in  any  other  form  of  the 
disease,  but  even  then  it  cannot  be  proved  that  the  skin  has  served  as  the 
primary  port  of  entry  for  the  tubercle  bacillus.  The  fact  is  that  at  the 
autopsies  of  children  with  lupus,  which  are  quite  uncommon,  organic  tuber- 
culosis is  always  found  although  perhaps  only  in  the  form  of  small  caseated 
lymph  nodes  or  as  old  fibrous  foci.  Accordingly,  the  cutaneous  disease 
must  be  considered  a  secondary  infection,  suggesting  an  acquired  hyper- 
sensibility,  which  leads  to  the  usually  very  characteristic  skin  changes,  the 


DISEASES  OF  THE  SKIN  819 

specific  nature  of  which  is  now  generally  recognized.  This  secondary  infec- 
tion of  the  skin  is  either  ectogenous  or  endogenous.  An  iso  ated  upus  in 
the  vicinity  of  the  nose,  probably  arises  ectogenously,  while  multiple  dis- 
seminated cutaneous  lesions  can  be  traced  only  to  an  endogenous  source. 

If  one  who  shows  tuberculous  skin  changes  be  injected  with  tuberculin, 
the  areas  of  cutaneous  reaction  show  an  acute  inflammatory  process,  a 
phenomenon  which  since  the  time  of  Koch  has  been  known  as  a  reaction. 
Skin  lesions  of  a  non-tuberculous  nature  are  entirely  unaffected  by  the 
injection.  The  specificity  of  this  phenomenon  is  absolutely  determined. 
It  is  possible,  in  doubtful  cases,  to  determine  the  tuberculous  or  non- 
tuberculous  character  of  the  skin  disease  in  question  in  this  simple  manner. 

Another  question  of  secondary  importance  is  whether  the  skin  lesion 
under  consideration  is  caused  by  living  or  dead  bacilli,  or  whether  it  is 
caused  only  by  the  poisonous  products  or  endotoxins  of  the  bacteria. 
This  question  has  aroused  much  interest  and  has  been  the  subject  of  much 
discussion.  The  bacillary  origin  of  lupus  and  scrofuloderma,  has  been 
established,  however  for  a  considerable  period  of  time.  As  a  result  of  very 
careful  examinations  by  Leiner,  Spieler  and  Zieler,  we  know  that  bacilli  or 
bacillary  debris  can  be  demonstrated  in  numerous  other  skin  conditions  of  a 
tuberculous  nature.  Nevertheless,  we  should  hardly  be  justified  in  drawing 
the  conclusion  from  this  fact  that  all  the  cutaneous  conditions  under  consid- 
eration are  always  of  a  purely  bacillary  nature.  For,  aside  from  numerous 
negative  findings,  we  often  see  essentially  similar  changes  of  the  integument, 
especially  in  lichen  and  acne,  and  when  tuberculin  has  been  rubbed  into 
the  skin,  even  though  finely  filtered  tuberculin  is  used  in  which  there  can  be 
no  question  surely  of  bacillary  debris.  For  this  reason,  a  differentiated  class- 
ification of  the  tuberculous  skin  disease  which  shows  an  attempt  to  divide 
them  into  true  or  actual  tuberculosis  and  tuberculoid  forms  is,  narrowly 
speaking,  impossible,  since  one  and  the  same  process  as,  for  example,  in 
lichen  scrofulosum,  may  be  at  one  time  of  a  bacillary  nature,  and  at  an- 
other non-bacillary. 

In  using  the  term  tuberculide  in  the  ensuing  pages,  it  is  not  meant  to 
recognize  a  condition  differing  in  principle  from  lupus  or  scrofuloderma. 
The  most  important  and  characteristic  point  in  all  these  processes  is  the 
specific  reaction  of  an  oversensitive  skin  to  an  invading  antigen.  The  term 
tuberculide  is  retained  merely  for  clinical  reasons,  as  are  other  subdivisions 
of  the  several  forms  of  reaction  to  be  regarded  as  for  clinical  and  diagnostic 
purposes  alone. 

LUPUS 

The  characteristic  structural  element  of  lupus  is  the  typical  nodules,  a 
small,  remarkabty  soft,  brownish-red  infiltrate  which  at  first  lies  embedded 
in  the  skin.  Its  color  does  not  disappear  when  pressure  is  put  upon  it  with  a 
microscope  slide,  although  it  becomes  slightly  paler  and  peculiarly  trans- 
parent. These  nodules  are  always  multiple.  If  they  become  confluent  in 
areas  where  they  are  crowded  together,  flat  subepithelial  infiltrates  result, 
above  which  the  epidermis,  deprived  of  its  nutrition,  desquamates  in  large 


820 


TEXT-BOOK  OF  PEDIATRICS 


scales.    At  the  edge  of  these  infiltrated  areas  new  nodules  appear,  which  by 
their  vertical  growth  gradually  rise  from  their  original  bed  above  the  level  of 

the  normal  skin  and  often  completely 
surround  the  squamous  area  of  lupus. 
This  is  the  usual  picture  of  lupus  vul- 
garis,  as  it  is  most  frequently  seen  on  the 
face  and  especially  on  or  about  the  nose 
(Figs.  231-4).  In  cases  of  favorable  termi- 
nation, this  lightest  form  quickly  shows 
a  tendency  to  involution  and  goes  on  to 
the  formation  of  a  slight  superficial  scar 
of  peculiar  silky  sheen,  in  which  the 
original  lupus  infiltrates  are  hardly  dis- 
coverable. More  frequently,  however, 
there  is  a  tendency  to  ulcerative  degener- 
ation in  the  broken  down  papules  and 
nodules.  Ulcers  of  variable  size  result 
which  are  rapidly  encrusted.  If  these 


Flo.  233. — Lupus  of  nose  and  face.    Typical 
lupus  nodules  at  the  edge  of  the  plaques. 

crusts  be  removed,  the  soft  base  of  the 
ulcers,  often  covered  with  ragged  granu- 
lations, readily  bleeds.  If  rapidly  ad- 
vancing proliferations  of  epithelial  and 
connective  tissue  cells  develop  at  the  edges 
of  the  ulcer,  wart-like  new  growths  appear 
(lupus  v err ucosus)j  which  on  the  face  often 
lead  to  elephantine  thickening  of  the  entire 
affected  area.  Lupus  verrucosus,  however, 
is  most  frequently  seen  on  the  extremities 
and  especially  on  the  extensor  surfaces. 
In  this  location  it  may,  at  times,  b'e  of  the 
multiple  and  disseminated  type  and  with 
the  qualities  of  an  acute  exanthem,  which 
is  doubtless  indicative  of  a  metastatic 
hernatogenous  infection. 

A  serious,  but  quite  frequent  compli- 
cation of  lupus,  is  its  extension  to  neigh- 
boring mucous  membranes  where  it  may 
be  terribly  destructive.  The  distressing 
facial  deformities,  the  bluish-red  shrunken  nose,  eaten  away  upon  all  sides, 
the  nares,  enlarged  and  everted  by  the  destruction  of  the  alse,  suggest  the 
physiognomy  of  a  mummy. 


FIG.  234. — Disseminate  lupus  of  skin. 


DISEASES  OF  THE  SKIN 


821 


If  a  differential  diagnosis  between  syphilis  and  lupus  has  to  be  con- 
sidered, it  is  to  be  made  by  the  Wassermann  test  and  the  tuberculin  reaction. 

Treatment. — In  the  early 
stages,  excision  and  skin  grafting 
are  indicated,  chiefly  for  cos- 
metic reasons.  Lupus,  in  itself, 
is  not  a  cause  for  great  anxiety, 
since  there  is  always  an  earlier 
and  initial  tuberculosis  to  be 
considered.  Very  good  results 
are  often  obtained  by  the  use  of 
pyrogallol  in  the  form  of  a  ten 
per  cent,  ointment.  This  is  to 
be  applied  twice  a  day  in  a  thick 
layer  on  sterile  lint.  If  this  has 
the  desired  effect  of  producing 
inflammation  and  an  eschar,  the 
treatment  is  continued  with  the 
use  of  a  solution  of  aluminum 
acetate.  Usually  it  will  be  found 
necessary  to  repeat  the  process 
several  times  and,  if  possible, 
until  all  lupus  nodules  have  dis- 
appeared. This  is  followed  by 
inunction  with  zinc  ointment. 
The  Einsen  ray  gives  better  results  than  the  Roentgen  ray.  So  far  no 
favorable  results  have  been  seen  from  tuberculin  treatment. 

SCROFULODERMA 

This  term  is  applied  to  tuberculous  skin  lesions  which  begin  with 
nodular  infiltration  of  the  derma  and  which  almost  invariably  go  on  to 
purulent  softening.  Sometimes  the  nodules  disappear  spontaneously  after 
persisting  for  months.  Usually  they  rupture  and  pus  is  discharged  exter- 
nally. The  nodules  frequently  arise  from  a  specific  infection  of  a  lymph 
node.  In  other  cases,  however,  they  appear,  whether  single  or  multiple,  as 
initial  indolent  infiltrations  of  the  skin.  They  vary  from  one-half  to  one 
and  a  half  centimeters  in  diameter.  At  first  they  do  not  differ  in  color 
from  the  normal  skin,  but  later  they  become  a  livid  red  and  of  glossy  sur- 
face. These  formations  are  called  scrofulous  gummata,  but  the  term  is  not  a 
very  appropriate  one  since  the  word  gumma  should  be  reserved  for  syphi- 
litic conditions. 

Commonly  the  scrofuloderma  develops  in  the  form  of  bluish,  broken- 
down,  and  readily  bleeding  granulations  around  the  perforate  openings  of 
specifically  infected  lymph  nodes,  bones  or  joints.  Essentially  this  repre- 
sents nothing  more  nor  less  than  a  continuous  cutaneous  auto-reaction  to 
the  influence  of  the  tuberculotoxic  pus,  voided  by  the  organism,  upon  its 
own  specifically  hypersensitive  skin.  This  reaction  is  never  produced 


FIG.  235. — Lupus  vulgaris.  (Courtesy  of  H,  H,  Hazen.) 


822  TEXT-BOOK  OF  PEDIATRICS 

around  fistulous  exits  by  non-specific  pus.  The  fistulous  tract,  of  course, 
responds  similarly  and  this  is  why  with  a  persistently  increased  local 
hypersensitivity  the  surrounding  tissues  show  so  great  a  tendency  to  necro- 
sis and  ulceration  rather  than  to  permanent  healing.  It  is  quite  obvious 
that  such  areas  must  leave  large  and  irregular  scars  which,  by  means  of 
their  blue  discoloration,  announce  their  origin  even  after  many  years. 

In  the  treatment  of  scrofuloderma,  the  wonderful  results    of    direct 
sunlight  have  forced  the  benefits  obtained  by  surgical  interference  or  by 


FIG.  236. — Lupus  vulgaris.  (Courtesy  of  H.  H.  Hazen.) 

the  tuberculin  therapy  into  the  background.    X-ray  therapy  has  given 
excellent  results. 

LICHEN,  ACNE,  ECZEMA 

Since  the  days  of  Hebra  the  classical  lichen  scrofulosorum  has  been 
defined  as  a  superficial  exanthem,  occurring  in 'a  group  form,  in  tuberculous 
individuals,  developing  slowly  from  nodules,  varying  from  a  millet-seed 
to  a  pinhead  in  size,  of  yellowish-brown  or  livid  red  color  which  protrude 
but  slightly  above  the  surface  of  the  skin.  These  nodules  itch  very  little. 
They  are  soon  covered  by  very  small  scales,  and  undergo  involution  after 
persisting  unchanged  for  months.  Such  a  case  is  shown  in  Figure  237,  in 
which,  also,  the  typical  localization  in  the  small  of  the  back  is  to  be  noted. 

Pure  cases  of  lichen  scrofulosorum  are  relatively  rare.     Usually  other 


DISEASES  OF  THE  SKIN 


823 


forms  of  efflorescence  are  associated  in  the  lichen  area,  and  larger  papules, 
pustules  and  true  eczematous  nodules  may  be  scattered  through  it.  In 
contrast  to  pure  lichen  which  is  always  in  distinct,  sharply  circumscribed 
areas  of  the  size  of  a  hand,  these  combined  exanthemata  often  cover  large 
surfaces,  extending  at  times  over  the  entire  lower  portion  of  the  body  and 
especially  over  the  lower  extremities. 

Therapeutically,  the  application  of  cod-liver  oil  has  proven  the  most 
satisfactory  remedy. 

Acne  scrofulosum  is  another  exanthem,  closely  related  to  lichen,  and 
found  even  more  frequently  in  scrofulous  children.  Sometimes  it  is  com- 
bined with  lichen,  but  oftener  occurs  alone  and  is  localized  chiefly  on  the 


FIG.  237. 


crofulous  lichen.      (Children's  Hospital,  Munich,  Prof,  von   Pfaundler.) 


face,  the  nates  and  thighs.  It  occurs  in  the  form  of  a  discrete  reddish  nodule 
with  a  small  pustule  at  the  apex  surrounded  by  a  red  areola.  While  this  is 
only  of  the  size  of  a  pinhead  at  first,  it  grows  rapidly  to  the  size  of  a  pea. 
In  the  course  of  its  enlargement,  the  pustule  usually  dries  up  and  forms  a 
crust.  The  lesion  often  leaves,  similarly  with  the  papulo-necrotic  tubercu- 
lide,  a  flat  skin  scar  which  is  surrounded  by  a  pale  ring  of  pigment. 

As  with  lichen,  so  we  sometimes  see  typical  acne  nodules  arising  in  areas 
to  which  tuberculin  ointment  has  been  applied.  This  goes  to  show  that 
their  etiology  is  not  entirely  dependent  upon  bacterial  infections. 

The  same  is  true  of  scrofulous  eczema  Most  frequently  and  very  typi- 
cally it  appears  in  those  areas  where  the  skin  meets  specifically  inflamed 
mucous  membranes,  as  around  the  eyes,  on  the  eyelids,  on  the  cheeks, 
about  the  nostrils,  in  the  concha  and  the  external  ear,  and  particularly  in 


824  TEXT-BOOK  OF  PEDIATRICS 

the  fold  between  the  auricle  and  the  scalp.  Furthermore,  the  distinct  limi- 
tation of  these  eczemas  to  their  original  focus  and  their  slight  tendency  to 
superficial  spread  is  characteristic.  Their  reaction  to  tuberculin,  injected  at 
some  other  part  of  the  skin,  shows  their  specific  character  and  indicates  that, 
aside  from  the  exudative  diathesis,  the  essential  factor  to  be  considered  is 
tuberculosis.  Escherich  includes  all  of  these  skin  reactions  under  the  name 
of  scrofulides. 

THE  SMALL  PAPULAR  TUBERCULIDE  OF  INFANCY 

This  lesion  belongs  to  the  group  described  by  Boeck  as  papulosquamous 
tuberculides.  Hamburger  first  called  attention  to  the  great  diagnostic  sig- 
nificance of  this  condition  in  infancy. 

As  its  characteristic  central  scale  is  soon  cast  off  and  it  usuaUy  appears 
as  a  small  round  papule  it  is  permissible  to  describe  the  lesion  as  a  small 
papular  tuberculide. 

The  individual  lesion  is  no  larger  than  a  pinhead  or  at  most  a  small 
round  lentil.  It  is  circular  or  oval  in  form,  does  not  itch,  and  is,  at  first, 
either  pale  or  livid  red,  and  later  of  a  light  brown  color.  The  absence  of  any 
necrosis  or  ulceration,  the  existence  of  a  slight  depression  at  the  centre  of 
the  papule  and  its  glossy  appearance  when  the  skin  is  stretched,  are  pecul- 
iar. The  fact  that  these  papules  appear  in  small  numbers  is  especially 
characteristic.  Usually  there  are  not  more  than  three  or  four  papules  to  be 
found;  at  times,  indeed,  but  a  single  specimen. 

The  exanthem  occurs  on  the  abdomen,  the  chest  or  shoulders  or  on  the 
extremities.  Its  localization  is  not  typical.  This  diagnostic  sign  may  put 
the  physician  upon  the  right  track  at  once.  Confusion  with  small  hemor- 
rhagic  or  cachectic  strophulus  is,  of  course,  possible.  For  this  reason  it  is  al- 
ways well  to  apply  a  cutaneous  tuberculin  test  before  making  a  final  diagnosis 

THE  PAPULO-NECROTIC  TUBERCULIDE 

This  form  occurs  most  frequently  on  the  extensor  surfaces  of  the  extrem- 
ities. Occasionally  it  is  found  also  on  other  parts  of  the  body,  as  on  the 
buttocks  or  on  the  auricle. 

Its  lesions  arise  from  the  deeper  layers  of  the  skin.  On  the  surface  they 
form  large  nodules  varying  from  one-fourth  to  one-half  a  millimeter  in 
diameter.  They  soon  show  a  distinct  tendency  to  necrosis  and  ulceration 
at  their  apices.  At  this  stage  a  dirty  brown  crust  formed  is  on  these  summits, 
the  removal  of  which  leaves  a  crater-like  base  which  bleeds  as  readily  as  a 
lupus.  Thepapulesarenever  very  close  together;  indeed,  the  crop  is  scattered 
but  much  more  numerous  than  in  the  small  papular  form  of  tuberculide. 

Very  often  the  papulo-necrotic  tuberculide,  accompanied  by  scrofulous 
lichen,  appears  after  measles  and  usually  about  fourteen  days  after  the 
exanthem  has  disappeared.  That  it  persists  for  a  long  time  is  due  chiefly 
to  repeated  new  crops  of  lesions  which  keep  up  the  process.  The  scars  left 
by  necrotic  tuberculides  are  very  typical.  They  appear  as  round  white 
spots,  somewhat  below  the  surface  of  the  skin  and  are  surrounded  by  a. 
pigmented  areola. 


URTICARIA  PIGMENTOSA 

(XANTHELASMOIDEA) 

Definition. — Urticaria  pigmentosa  is  a  rare  affection  usually  beginning 
in  the  first  year,  characterized  by  the  gradual  development  of  wheals, 


Fid.  1. — Urticaria  pigmentosa.  (Courtesy  of  II.  H.  llazen. 

which  are  followed  by  pigmented  lesions  either  macules,  papules  or  nodules 
having  a  marked  tendency  to  persist 

825 


826  TEXT-BOOK  OF  PEDIATRICS 

Symptoms. — While  the  disease  usually  begins  in  the  first  few  months  of 
life,  cases  are  now  recorded  appearing  in  young  adults.  Wheals  are  the 
first  lesions  to  appear,  rapidly  followed  by  tan  or  brownish-red  pigmented 
lesions  which  may  be  either  macules,  papules  or  nodules.  All  types  may 
appear  in  the  same  case.  The  lesions  are  most  abundant  on  the  trunk, 
particularly  on  the  back  and  buttocks,  and  the  neck.  The  extremities  may 
also  be  involved.  In  size  the  lesions  range  from  a  pea  to  a  bean  and  are 
usually  numerous.  Irritation  produces  wheals  on  the  unaffected  skin. 
Where  the  pigmented  lesions  are,  itching  may  be  intense  or  slight.  The 
disease  usually  runs  a  persistent  course  tending  to  disappear  spontaneously 
at  puberty. 

Differential  Diagnosis. — The  itching  and  wheals  suggest  urticaria  but 
the  pigmented  lesions  are  distinctive.  Cases  of  generalized  xanthoma 
while  similar  in  appearance  fail  to  produce  wheals  upon  irritation.  The 
microscopic  picture  with  mast  cell  infiltration  is  also  characteristic. 

Etiology. — A  definite  or  specific  cause  is  unknown,  it  is  likely  that  it 
depends  upon  a  congenital  disturbance. 

Prognosis. — Life  is  not  affected  and  the  disease  is  likely  to  finally  disappear. 

Treatment. — Treatment  should  be  directed  to  the  amelioration  of  itch- 
ing when  present,  using  antipruritics  as  in  urticaria.  Every  effort  should  be 
made  to  improve  the  general  condition  paying  particular  attention  to  proper 
diet.  There  is  no  treatment  which  affects  the  courses  of  the  disease. 

HERPES  SIMPLEX 
(HERPES  FEBBILIS,  HERPES  LABIALIS,  COLD  SORES,  FEVER  BLISTERS) 

Definition. — Herpes  simplex  is  an  acute,  grouped  eruption  of  vesicles 
appearing  most  frequently  at  a  muco-cutaneous  junction. 

Symptoms. — The  eruption  is  proceeded  by  burning  and  tingling  and 
perhaps  some  redness  and  swelling.  The  vesicles  are  at  first  tiny,  tense, 
glistening  and  from  two  or  three  to  a  dozen  in  number,  filled  with  clear 
fluid  which  may  become  red  from  hemorrhage  or  purulent  from  infection. 
After  a  few  days  they  become  flaccid  and  dry  into  a  crust  which  shortly 
falls  off  leaving  a  pinkish  surface  beneath.  The  eruption  may  appear 
around  the  mouth  or  nostrils,  on  the  face,  eyelids  or  in  the  mouth.  As  a 
rule  the  attack  lasts  only  a  few  days  but  recurrent  varieties  occur,  some- 
times extending  over  a  period  of  years.  The  disease  is  designated  according 
to  location  as  herpes  labialis,  progenitalis,  etc. 

Differential  Diagnosis. — 'The  diagnosis  usually  offers  little  difficulty,  al- 
though it  may  be  confused  with  zoster  when  unilateral  and  with  impetigo, 
particularly,  when  infection  takes  place. 

Etiology. — There  is  no  specific  cause  but  the  eruption  is  frequently  ex- 
cited by  gastro-intestinal  disturbances,  colds,  acute  exanthemata  or  other 
febrile  affections.  In  those  disposed,  even  slight  local  irritation  may  pre- 
cipitate an  attack. 

Treatment. — When  seen  just  previous  to  the  eruption  of  vesicles  the 
attack  may  be  aborted  by  painting  the  area  with  collodion.  Frequent 


EXUDATIVE  DERMATOSIS 


827 


application  of  spirits  of  camphor  serve  to  relieve  and  possibly  shorten  the 
course.  When  the  vesicles  have  ruptured,  antiseptic  salves  to  prevent 
infection  are  indicated,  10  per  cent,  boric  acid  in  lanolin  and  petrolatum  is 
particularly  useful,  as  it  matters  not  if  the  child  gets  it  into  the  mouth  or 
eyes  in  rubbing.  If  infection  has  taken  place  ammoniated  mercury  oint- 
ment is  serviceable.  When  the  lesions  occur  around  the  corners  of  the 


FIG.  2. — Herpes  simplex.     (Courtesy  of  Howard  Fox.) 

mouth  and  result  in  fissures,  these  may  be  painted  with  tincture  of  benzoin 
or  healed  by  mechanically  drawing  the  parts  together  and  holding  with 
adhesive  tape  or  collodion. 

HERPES  ZOSTER 

(ZONA,  SHINGLES) 

This  disease  occurs  very  frequently  in  children.  It  is  characterized  by  a 
unilateral  grouped  vesicular  eruption  on  a  reddened  base,  appearing  most 
frequently  on  the  trunk.  It  is  self-limiting  in  its  course  and  usually  meas- 
ures need  be  taken  only  to  protect  the  lesions  and  prevent  infection. 
A  ten  per  cent,  boric  acid  salve  is  practical  for  this  purpose. 

PEMPHIGUS 

The  term  pemphigus  was  formerly  applied  to  almost  any  bullous  erup- 
tion and  until  comparatively  recent  date,  there  was  confusion  between 
pemphigus  neonatorum  and  true  pemphigus  particularly.  The  term  is  now 
limited  to  a  definite  group  of  diseases  characterized  by  the  spontaneous 


828  TEXT-BOOK  OF  PEDIATRICS 

development  of  bullae.  Pemphigus  occurs  in  four  varieties,  pemphigus 
vulgaris  or  chronicus,  pemphigus  acutus,  pemphigus  foliaceus  and  pem- 
phigus vegetans. 

PEMPHIGUS  ACUTUS 

Pemiphigus  acutus  is  applied  to  a  rather  rare  acute  form  of  the  disease 
usually  of  a  definite  toxic  nature  occurring  most  frequently  in  butchers  and 
others  particularly  exposed  to  infection  and  frequently  of  fatal  termination. 
It  is  exceedingly  rare  in  childhood. 

PEMPHIGUS  FOLIACEUS 

Pemphigus  foliaceus  is  a  type  where  exfoliation  persistently  follows  the 
bullae  until  it  is  general.  This  is  also  rare  in  childhood. 

PEMPHIGUS  VEGETANS 

Pemphigus  vegetans  is  exceedingly  rare,  occurs  usually  in  the  middle- 
aged  and  is  characterized  by  vegetative  growths  following  the  bullae  with 
their  excoriations. 

PEMPHIGUS  VULGARIS 

This  is  the  type,  especially,  which  is  understood  when  the  term  pemphi- 
gus is  used  It  is  a  disease,  usually  chronic,  characterized  by  the  primary 
development  of  crops  of  bullae. 

Symptoms. — The  eruption  may  or  may  not  be  preceded  by  a  slight 
period  of  malaises  and  fever,  a  few  blebs  arise  which  either  dry  or  break  and 


FIG.  3. — Pemphigus  vulgaris. 

crust.  The  lesions  are  tense  or  flaccid,  and  contain  serum,  pus  or  blood. 
'The  bullae  usually  appear  in  crops,  have  no  inflammatory  halo,  and  are 
followed  by  slight  pigmentation.  Mucous  membranes  are  commonly 
involved.  With  the  appearance  of  the  eruption  there  may  be  a  rise  of  two  to 
four  degrees  in  temperature,  considerable  prostration,  nephritis,  entero- 
colitis  and  a  slight  leucocytosis  with  a  relative  increase  in  the  neutrophiles. 


EXUDATIVE  DERMATOSIS  829 

Course. — The  disease  may  last  for  months  or  years  or  may  terminate  in 
one  of  the  other  types.  There  may  be  little  effect  upon  the  general  health. 

Differential  Diagnosis. — Once  the  disease  is  established  there  is  little 
question  of  the  diagnosis  because  of  the  non-inflamed  base  and  slow  course 
of  the  disease. 

Etiology. — While  micro-organisms  have  been  found  there  is  no  proof  of 
their  being  the  causative  agent.  The  cause  is  actually  unknown. 

Treatment. — Arsenic  pushed  to  the  limit  is  sometimes  of  benefit. 
Everything  should  be  done  to  better  general  conditions  and  focal  infection 
should  receive  special  attention.  Locally  dusting  powder  generously  ap- 
plied is  the  most  satisfactory,  ointments  are  ordinarily  not  well  borne.  The 
permanganate  bath  is  of  value. 

Prognosis. — Patients  may  survive  for  years  but  most  of  them  finally 
succumb.  The  benign  form  which  is  occasionally  seen  and  which  disap- 
pears after  a  few  months  is  a  questionable  pemphigus,  most  authorities  are 
agreed  that  pemphigus  is  always  fatal. 

EPIDERMOLYSIS  BULLOSA 

This  is  a  rare  hereditary  and  familial  disease  characterized  by  the  for- 
mation of  bullae  as  a  result  of  trauma.  The  general  health  is  unaffected.  It 


FIG.  4. — Epidermolysis  bullosa.     (Courtesy  of 
Richard  L.  Sutton.) 

is  not  affected  by  treatment.    The  first  signs  appear  shortly  after  birth.    It 
is  presumably  due  to  a  malformation  of  the  elastic  tissue. 

HYDROA  VACCINIFORME 

This  disease  is  also  known  as  herpes  aestivalis  or  recurrent  summer 
eruption.    It  occurs  only  in  childhood  and  usually  in  boys.      The  eruption 


830  TEXT-BOOK  OF  PEDIATRICS 

consists  of  vesicles  or  small  bullae  which  occur  on  the  exposed  surfaces  such 
as  the  face,  hands  and  forearms.    These  break  and  crust  leaving  depressed 


FIG.  5. — Hydroa  vacciniforme.     (Courtesy  of  Richard  L.  Sutton.) 

scars.  It  is  due  to  some  malformation  of  the  skin  which  makes  it  susceptible 
to  light.  There  is  no  cure  for  the  disease  but  it  spontaneously  disappears 
at  adolescence. 

INFLAMMATIONS  OF  THE  SKIN 

DERMATITIS  VENENATA 

Definition. — An  acute  erythematous  or  vesicular  inflammation  caused 
by  an  external  chemical  irritant.  Under  this  title  are  usually  described 
various  types  of  dermatitis  due  to  chemicals  such  as  mustard,  cantharides, 
croton  oil,  mercury,  iodine,  turpentine,  etc.,  and  vegetable  irritants  such  as 
rhus  toxicodendron  (poison  ivy).  The  latter  may  be  taken  as  a  type  inas- 
much as  it  is  most  common. 

Symptoms. — In  slight  cases  only  a  dry  erythema  occurs.  More  fre- 
quently it  produces  an  acute  vesicular  dermatitis  and  occasionally  a  violent 
inflammation  with  marked  redness  and  swelling  accompanied  by  the  for- 
mation of  large  tense  bullae.  The  exposed  parts  are  naturally  most  fre- 
quently affected,  such  as  the  hands,  feet  and  face  although  other  parts  may 
be  involved  especially  around  the  genitals  and  anus.  Not  infrequently  with 
lack  of  care  or  wrong  treatment  a  more  or  less  general  dermatitis  com- 
plicates the  situation.  The  eruption  usually  develops  immediately  or 
within  a  few  hours  after  exposure.  There  is  usually  considerable  burning 
and  itching  and  in  severe  cases  constitutional  symptoms  such  as  fever  of 
101°  or  102°  F. 


EXUDATIVE  DERMATOSIS  831 

Diagnosis. — Characteristic  eruption  on  exposed  parts  with  history  of 
exposure. 

Treatment. — If  the  diagnosis  is  unquestionable, radical  treatment  maybe 
used,  such  as  washing  the  affected  parts  with  strong  soap  and  water  with  a 
brush  or  scrubbing  with  50  to  90  per  cent,  alcohol  to  remove  the  irritating 
oil.  This  treatment  is  followed  by  calamine  lotion  or  a  bland  ointment. 

With  a  dermatitis  in  which  the  diagnosis  is  not  so  clear,  less  radical 
measures  are  better  and  there  is  less  danger  of  increasing  the  inflammation. 
Solutions  of  lead  are  presumed  to  precipitate  the  oil.  The  following  is  best : 

Plumbi  acitatis 5.0 

Pulvis  alumin 1.0 

Aquae  dest 100.0 

M.  ft. 

Sig. — Dilute  with  5  to  10  parts  of  water 

and  apply  on  gauze. 

This  application  should  be  used  cold  on  thick  compresses  of  gauze  and 
kept  moist.  Oil  silk  may  be  used  over  the  gauze  for  twenty-four  hours  to 
hasten  maceration  and  rupture  of  the  vesicles  and  bullae.  When  the  erup- 
tion is  dry,  treatment  may  be  changed  to  bland  protectives  such  as  zinc 
paste  or  the  following  is  exceedingly  useful  and  practical : 

Zinci  oxididi 

Amyli 

Glycerinac 

Aquae  aa  30.0 

M.  ft. 

Sig. — Paint  on  several  times  a  day. 

This  application  has  the  advantage  of  " sticking  on"  and  if  dusting 
powder  is  applied  on  top  it  does  not  soil  the  clothing  as  much  as  an  ointment. 


DRY  SCALY  INFLAMMATORY  DERMATOSES 

PlTYRIASIS  ROSEA 

(HERPES  TONSURANS  MACULOSUS,  PITYRIASIS  CIRCINATA) 

Definition. — Pityriasis  rosea  is  a  disease  of  the  skin,  characterized  by 
the  development  of  symmetrically  distributed  macules  or  patches,  which  are 
round  or  circinate  in  outline,  slightly  scaly  and  of  a  pinkish-red  color.  It 
occurs  at  all  ages  but  only  occasionally  in  childhood. 

Symptoms. — There  is  usually  a  single  lesion  that  appears  first  which  is 
known  as  the  "mother  spot,"  this  is  followed  in  a  few  days  by  other  pink- 
red  papules.  The  lesions  tend  to  enlarge  and  become  patchy  and  scaly. 
They  are  confined  largely  to  the  trunk  but  may  appear  on  the  face,  shoul- 
ders or  thighs.  Central  healing  takes  place  making  circinate  lesions.  The 
eruption  usually  disappears  in  two  to  four  weeks. 

Etiology. — Unknown . 


832 


TEXT-BOOK  OF  PEDIATRICS 


Diagnosis. — Distinguished  from  ringworm  by  lack  of  fungus.     From 
psoriasis  by  its  fine  bran-like  scales,  location  and    lack   of   infiltration. 


FIG.  6. — Pityriasis  rosea. 

Treatment. — Salves  containing  salicylic  acid  and  sulphur. 

Acidi  salicyhcii 1.0 

Sulphuris  lac 3.0 

Zinci  Oxidi 20.0 

Amyli .' . .  20.0 

Glycerime 30.0 

Aquse  Best 30.0 

M.  ft. 

Sig. — Apply  several  times  daily. 

PSORIASIS 

While  psoriasis  is  one  of  the  most  common  skin  diseases,  it  is  only, 
occasionally  seen  in  children,  although  cases  even  in  infancy  are  reported. 
The  eruption  appears  in  the  form  of  variously  sized  and  shaped  macules  or 


EXUDATIVE  DERMATOSIS 


833 


papules,  which  almost  immediately  show  scaling.    The  scales  are  character- 
istically silvery  and  rather  adherent,  particularly  the  underlying  ones.     The 


FIG.  7. — Pityriasis  rosea.     (Courtesy  of  H.  H.  Hazcn.> 

extensor  surfaces  of  the  arms  and  legs,  especially  the  elbows  and  knees  and 
the  scalp  are  most  frequently  involved.    It  is  likely  to  run  a  chronic  course 


FIG.  S. — Psoriasis. 


with  relapses  from  time  to  time.    While  a  large  amount  of  investigation  has 
been  made,  the  etiology  continues  to  be  unknown.    Treatment  consists  of 
putting  the  patient  in  the  best  possible  condition;  focal  infection,  gastro-in- 
53 


834  TEXT-BOOK  OF  PEDIATRICS 

testinal  disturbances  and  diet  being  important  factors.  Locally,  daily  baths 
and  ointments  are  indicated.  The  list  of  drugs  advised  in  psoriasis  is  almost 
endless.  For  the  more  acute  cases  salicylic  acid  and  sulphur  3  and  5  per  cent, 
or  ammoniated  mercury  5  to  10  per  cent,  are  valuable.  In  old  chronic  cases 
with  a  few  plaques,  pyrogallic  acid  or  chrysarobin  10  to  15  per  cent,  are 
good,  both  produce  a  dermatitis  and  neither  should  be  used  on  the  scalp. 
Ultra-violet  light  and  X-ray  properly  applied  will  cause  disappearance  of 
the  lesions.  Recently,  raying  of  the  thymus  gland  has  been  reported  suc- 
cessful by  Foerster.  Arsenic  was  formerly  used  and  it  is  frequently  of  service, 
it  is  questionable,  however,  with  the  frequent  recurrences,  whether  it  is 
advisable  as  a  routine,  on  account  of  the  danger  of  arsenical  keratoses  fol- 
lowing its  unrestricted  use. 

INFECTIOUS  DISEASES  OF  THE  SKIN 
GRANULOMA  PYOGENICUM 

Granuloma  pyogenicum  is  a  term  applied  to  a  slow  developing,  usually 
pedunculated  tumor  one-fourth  to  one-half  inch  in  diameter,  arisinguponthe 
site  of  an  injury.  The  lesions  are  usually  single,  the  size  of  a  pea  or  bean 
and  bright  red  in  color.  They  occur  most  frequently  upon  exposed  surfaces. 


FIG.  9. — Granuloma  pyogenicum.  (Courtesy  of  Richard  L.  Sutton.) 

The  surface  may  be  smooth  or  cauliflower-like  with  purulent  secretion  in 
the  crypts.  It  is  presumably  due  to  infection  with  staphylococcus.  The 
lesion  persists  indefinitely  and  unless  properly  removed,  recurs.  Removal 
with  electric  cautery  is  the  best.  The  tumor  may  be  excised  and  the  base 
thoroughly  cauterized  with  zinc  chloride. 

FAVUS 

(TINEA  FAVOSA) 

Favus  is  a  fungus  disease,  usually  limited  to  the  scalp,  occurring  pri- 
marily in  childhood  but  not  always  disappearing  with  adolescence,  as  other 
forms  of  tinea.  It  is  seen  infrequently  in  this  country  and  usually  in  im- 
migrants. It  may  appear  on  the  body  or  nails.  The  characteristic  lesion 
starts  as  a  papule  around  the  hair  follicle,  followed  by  a  dirty  yellowish  crust 


EXUDATIVE  DERMATOSIS  835 

with  concave  surface.    There  is  loss  of  hair.    Diagnosis  is  made  by  char- 
acteristic lesion  and  microscopic  demonstration  of  the  fungus.    Treatment 


FIG.  10. — Favus. 

consists  of  epilation  by  X-ray  followed  by  antiseptic  applications  to  bald 
scalp.  Precautions  should  be  observed  to  prevent  the  spread.  Baldness 
produced  by  the  disease  is  permanent. 

TINEA  TRICHOPHYTINA 
(RINGWORM,  TRICHOPHYTOSIS) 

Tinea  trichophytina  or  ringworm  is  a  local  infectious  disease  of  the 
skin  due  to  the  trichophyton  fungi.  The  various  conditions  produced  by 
these  fungi  may  be  classified  according  to  the  nature  of  the  fungus  or 
according  to  the  part  involved,  the  latter  is  by  far  the  most  practical,  partic- 
ularly in  this  work  where  only  the  ones  of  importance  to  the  podiatrist  are 
to  be  described. 

TINEA  TRICHOPHYTINA  CORPORIS 
(TINEA  CIRCINATA;  RINGWORM  OF  THE  BODY;  TRICHOPHYTOSIS  CORPORIS) 

Symptoms. — Ringworm  of  the  non-hairy  skin  begins  as  a  flattened 
pinkish  papule  with  a  tendency  to  spread  peripherally  and  clear  up  in  the 
centre.  As  the  lesions  enlarge  they  become  ring-shaped,  usually  with  a 
sharply  marked  border  and  pinkish  or  brownish  furfuraccous  centre.  Com- 
bined lesions  form  gyrate  figures.  Spontaneous  healing  may  take  place. 
Subjective  symptoms  are  not  often  present.  The  uncovered  portions  of  the 


836  TEXT-BOOK  OF  PEDIATRICS 

body  are  most  frequently  involved.     The  deeper  parts  of  the  skin  may  be- 


FIG.  11. — Tinea  circinata.     (Courtesy  of  Howard  Fox.) 

come  involved,  giving  a  papulo-pustular  lesion,  carbunculoid  in  appearance. 

TINEA  TRICHOPHYTINA  CRURIS 
(TINEA  CRURIS  :  ECZEMA  MARGINATUM  :  DHOBIE  ITCH) 

This  variety,  together  with  that  occurring  occasionally  in  the  axillse 
and  on  the  hands  and  feet  is  usually  due  to  the  epidermophyton  inguinal. 
The  cruris  type  is  rarely  seen  in  children,  it  does  not  differ  from  the  others 
except  in  location  and  the  tendency  to  vesicle  or  pustule  formation  along 
the  border.  The  condition  caused  by  infection  with  this  fungus  on  the  hands 
and  feet  is  seen  in  children  as  an  eczematoid  dermatitis.  It  occurs  as  a 
vesicular  eruption,  frequently  grouped  and  sharply  marginated  on  the 
backs  of  the  hands,  between  the  fingers  and  similarly  on  the  feet.  Occa- 
sionally the  palms  and  soles  are  also  involved.  Between  the  fingers  and  toes 
the  skin  becomes  boggy  from  perspiration  and  peels  with  fissure  formation. 

Diagnosis. — Ringworm  of  the  body  is  to  be  differentiated  from  pityriasis 
rosea;  seborrhceic  dermatitis  and  psoriasis.  Ringworm  occurs  more  fre- 
quently on  the  uncovered  parts,  pityriasis  rosea  is  usually  limited  to  the 
trunk,  ringworm  is  more  frequently  limited  to  a  few  lesions,  pityriasis  rosea 
begins  with  one  lesion,  the  "mother  spot"  and  later  shows  quite  a  general 
eruption  pretty  well  covering  the  trunk,  individual  lesions  are  almost  iden- 
tical, only  microscopic  finding  would  definitely  differentiate  them.  In  sebor- 


EXUDATIVE  DERMATOSIS  837 

rhceic  dermatitis,  usually  the  sternal  and  interscapular  areas  are  the  principal 
ones  involved,  scales  are  greasy  and  there  is  no  tendency  to  vesicle  or  pus  for- 
mation. Psoriatic  lesions  are  always  dry,  may  be  ring-shaped  but  the  scales 
are  characteristically  silvery,  bleeding  points  occur  upon  scraping  scales 
away.  There  is  nearly  always  involvement  of  elbows,  knees,  or  scalp.  The 
eczematoid  ringworm  of  hands  and  feet  is  frequently  impossible  to  dif- 
ferentiate from  eczema.  When  both  hands  and  feet  are  involved  it  is 
more  likely  ringworm,  theoretically  one  might  depend  upon  the  microscope 
but  practically  the  fungus  is  frequently  so  hard  to  find  that  this  is  not  safe. 
Considerable  work  is  being  done  on  this  condition  but  it  still  remains  in 
considerable  confusion.  Specimens  for  the  microscope  are  made  by  taking 
scrapings  of  the  scales  or  the  tops  of  vesicles,  applying  30  per  cent,  sodium 
hydroxide  to  dissolve  the  tissue  and  in  one-half  hour  and  two  hours  the 
spores  and  fungi  may  be  seen. 

Etiology. — Infection  may  occur  by  direct  contact  or  through  the  use  of 
contaminated  articles,  hats,  underwear,  combs,  brushes,  etc.  The  infection 
exists  in  the  domestic  animals  and  is  frequently  contracted  from  them. 

Prognosis. — The  prognosis  of  ringworm  of  the  body  is  always  good. 

Treatment. — On  the  body,  the  condition  is  usually  soon  cleared  up, 
with  ointments  of  ammoniated  mercury  5  to  10  per  cent.,  sulphur  5  to  10 
per  cent,  or  Whitfield  ointment,  salicylic  acid  3  per  cent,  and  benzoic  acid  5 
per  cent.  Aqueous  solutions  of  sodium  hyposulphite  10  per  cent,  alone  or 
followed  by  a  solution  of  tartaric  acid  3  per  cent.  On  the  hands  and  feet  the 
lesions  are  frequently  more  rebellious,  the  above  mentioned  Whitfield 
ointment  may  be  used  until  peeling  takes  place  and  then  followed  by  zinc 
paste  or  crude  tar  ointment  may  be  used : 

Crude  tar 4.0 

Zinc  oxidi 4.0 

Amyli 30.0 

Petrolatum  Flav...30.0 

M.  ft.  Ung. 

Sig. — Apply  2  or  3  times  daily,  cleaning  off  with  sweet  oil. 

ONYCHOMYCOSIS 
(RINGWORM  OF  THE  NAILS) 

Ringworm  of  the  nails  may  occur  primarily  or  secondarily.  The  nails 
are  a  dirty  grayish  or  yellowish  color,  appear  worm  eaten  and  thickened. 
Fungus  is  found  with  difficulty  in  scrapings.  The  nails  should  be  scraped 
frequently  and  Whitfield  ointment  or  pure  crude  coal  tar  applied. 

TINEA  TRICHOPHYTON  CAPITIS 
(TINEA  CAPITIS:  TINEA  TONSURANS:  RINGWORM  OF  THE  SCALP) 

Symptoms. — Ringworm  of  the  scalp  is  definitely  a  disease  of  childhood, 
spontaneous  involution  taking  place  at  puberty.  It  starts  as  a  small  scaly 
patch  or  reddened  hair-perforated  papule.  The  base  is  reddened  but  the 
scales  are  whitish  or  grayish  in  color.  There  is  no  tendency  to  central 


838 


TEXT-BOOK  OF  PEDIATRICS 


FIG.  12. — Tinea  capitis.    (Courtesy  of  Howard  Fox.) 


FIQ.  13. — Tinea  capitis. 


EXUDATIVE  DERMATOSIS  839 

involution.  The  hair  becomes  lustreless  and  dry  and  many  broken  hairs  are 
seen  in  the  partly  bald  patch.  Occasionally  there  is  a  pustular  folliculitis. 

Diagnosis. — The  condition  as  described  above  is  characteristic  and  the 
diagnosis  is  easily  confirmed  by  examining  hairs  treated  with  sodium  hy- 
droxide solution. 

Prognosis. — The  prognosis  depends  upon  the  treatment,  with  older 
methods  of  epilation  and  treatment,  usually  recovery  was  a  matter  of  several 
years.  Epilation  with  X-ray  followed  by  applications  of  iodine  is  the  mod- 
ern accepted  treatment  and  the  time  is  reduced  to  a  few  months. 

Treatment. — The  older  methods  consisted  of  forcep  spilation  and  the 
application  of  various  antiseptic  salves.  Nowadays  the  entire  scalp  is 
epilated  with  X-ray,  the  hair  falling  out  from  one  to  three  weeks  after  expo- 
sure, depending  upon  the  method  used.  When  ttie  hair  is  out,  the  scalp  is 
painted  several  times  with  tincture  of  iodine.  The  hair  grows  in  again  in 
from  two  to  three  months.  If  necessary  epilation  can  be  repeated.  Obvi- 
ously this  treatment  should  only  be  undertaken  by  an  expert.  Precautions 
should  be  taken  to  prevent  spread  of  the  infection  to  others,  the  child  wear- 
ing a  skull  cap. 

DISEASES  OF  THE  APPENDAGES  OF  THE  SKIN 

(MILIAEIA) 

Miliaria  is  a  sweat  eruption  produced  by  the  retention  of  sweat  in  the 
sweat  follicles.  It  occurs  as  miliaria  crystallina  and  miliaria  rubra.  The 
lesions  of  the  first  are  non-inflammatory  and  the  second  inflammatory. 

Miliaria  crystallina  or  sudamina  is  characterized  by  an  eruption  of 
numerous  tiny  discrete  acuminate  vesicles.  The  vesicle  walls  are  very  thin 
and  rupture  easily.  It  is  produced  by  excessive  sweating  and  is  without 
subjective  symptoms.  It  is  usually  confined  to  the  trunk. 

Miliaria  rubra  (prickly  heat,  heat  rash)  is  an  eruption  of  miliary  vesicles 
and  papules  at  the  mouths  of  the  sweat  follicles.  The  lesions  are  minute, 
superficial,  thin-walled,  vesicles,  upon  an  inflamed  base.  The  contents  are 
at  first  clear  and  later  opalescent.  There  may  also  be  numerous  very  fine 
papular  or  papulo-vesicular  lesions.  The  lesions  are  usually  very  numer- 
ous giving  to  the  whole  area  where  they  occur  a  pinkish  appearance.  The 
sides  of  the  neck,  chest  and  back  are  the  usual  sites  but  other  parts  may 
be  affected.  There  is  always  burning,  pricking,  itching  and  marked  dis- 
comfort. There  is  frequently  an  accompanying  dermatitis  and  when  this 
occurs  in  the  folds  in  adipose  individuals  it  may  lead  to  an  intertrigo. 
The  diagnosis  is  not  difficult  when  the  associated  sweating  or  overheating 
together  with  the  characteristic  lesions  are  taken  into  consideration.  Mili- 
aria crystallina  requires  no  treatment  other  than  bathing  and  powdering. 
Miliaria  rubra  is  frequently  very  disturbing  and  requires  treatment  to  re- 
lieve the  itching,  otherwise  scratching  and  rubbing  are  likely  to  produce 
further  trouble.  Sponging  with  dilute  alcohol  (60  per  cent.)  and  pow- 


840  TEXT-BOOK  OF  PEDIATRICS 

dering  may  be  sufficient.     Calamine  lotion  applied  frequently  is  satisfac- 
tory.   A  practical  and  satisfactory  application  is : 

Zinci  oxide  Glycerinsc 

Amyli  aa  30.0  Aquso  dcst.  aa  60.0 

M.  ft.  in  unguent. 

Sig. — Apply  several  times  a  day. 

This  application  may  be  smeared  on  several  times  a  day  and  powder 
dusted  over  it.  Salves  should  not  be  used.  The  eruption  rarely  lasts  more 
than  a  few  days  unless  the  causes  are  permitted  to  continue.  Every  effort 
should  therefore  be  made  to, keep  the  child  cool  by  means  of  cool  baths 
and  light  clothing. 

MILIUM 

(STROPHULUS  ALBIDUS,  ACNE  ALBIDA) 

Milia  are  small  whitish  tumors  of  the  skin  formed  by  hardened  sebum 
beneath  the  epidermis.  These  pinhead  to  small  pea-sized  papules  usually 
occur  beneath  the  eyes.  They  may  also  be  seen  on  the  scrotum.  There  are 
usually  only  a  few  and  they  remain  discrete.  Milia  are  common  in  young 
adults  and  not  infrequently  seen  in  infants.  In  the  latter  vigorous  washing 
with  soap  and  water  will  dispose  of  them.  Later  in  life  it  is  necessary  to 
puncture  the  lesion  and  express  the  contents. 

COMEDO 

A  comedo  (blackhead)  is  a  plug  of  dried  sebaceous  material  which  fills 
the  opening  of  a  sebaceous  follicle.  They  are  more  frequently  seen  where 
the  sebaceous  glands  are  most  numerous  as  on  the  forehead,  nose,  nasolabial 
furrows,  chin,  chest,  and  back.  They  are  almost  constantly  associated 
with  acne  vulgaris  and  constitute  a  definite  part  of  that  disease. 

GROUPED  COMEDONES  IN  CHILDREN 

Groups  of  comedones  occurring  in  children  upon  parts  subjected  to 
pressure  and  warmth  have  been  described  by  Corcker.  They  are  seen  on 
the  cheeks  in  nursing  infants  and  on  the  forehead,  temples  and  occiput 
of  older  children. 

ACNE  NEONATORUM 

An  acne  occurring  on  the  forehead  and  nasal  folds  of  infants  has  been 
described  by  Kraus.  Both  comedones  and  pustules  are  present  and  they 
appear  to  have  the  characteristics  of  a  true  acne  due  to  a  disturbance  of 
sebaceous  secretion. 

ACNE  VULGARIS 

Acne  vulgaris  is  characterized  by  an  eruption  of  inflammatory  lesions, 
situated  in  the  sebaceous  follicles  consisting  of  comedones,  papules  and 
pustules.  The  lesions  are  found  where  the  sebaceous  glands  are  numerous, 
face  including  forehead,  nose,  cheeks  and  chin,  the  chest  and  back.  There 
is  usually  little  difficulty  in  the  diagnosis. 

Several  types  are  described  depending  upon  the  predominant  lesion  such 
as  acne  simplex,  acne  indurata,  acne  papulosa  and  acne  pustulosa.  Usually 


EXUDATIVE  DERMATOSIS 


841 


there  is  a  mixture  of  all  lesions.  Superficial  lesions  produce  no  scarring  but 
the  deep-seated  lesions  of  acne  indurata  do  produce  scars  and  this  is  one 
important  reason  for  treatment.  The  disease  is  most  pronounced  at  adoles- 
cence but  may  occur  in  younger  children.  In  the  superficial  types,  a  salve 
of  salicylic  acid  and  sulphur  with  plenty  of  soap  and  water  suffices.  The 
salicylic  acid  is  used  1  to  3  per  cent,  with  precipitated  sulphur  3  to  5  per 
cent.  If  many  comedones  are  present  they  should  be  mechanically  removed. 
In  the  pustular  and  indurated  types  the  lesions  need  to  be  surgically  opened 
in  addition.  Mixed  staphylococcus  vaccines,  150  million  to  400  million, 
four  days  to  a  week  apart,  help.  Ultra-violet  ray  given  to  the  point  of  pro- 
ducing a  dermatitis  is  of  decided  assistance.  In  severe  cases  the  X-ray  is  the 
best  agent  of  all  but  must  be  used  expertly  and  care  exercised  not  to  over- 
dose on  account  of  later  developing  telangiectases.  All  local  treatment 
should  be  accompanied  by  regulation  of  diet,  care  of  constipation,  removal 
of  focal  infection  and  adherence  to  all  measures  productive  of  good  hygiene. 
All  cases  can  be  cleared  up,  but  the  natural  tendency  is  to  relapse  and  there 
is  usually  a  need  for  considerable  care  for  several  years. 

ALOPECIA   AREATA 
Alopecia  areata  is  characterized  by  the  sudden  loss  of  hair  in  patches 


Fio.  14. — Alopecia  areata  totalis.    (Courtesy  of  Howard  Fox.) 

of  various  sizes  and  shapes.    There  may  be  one  or  many  areas. 


Recurrence 


842  TEXT-BOOK  OF  PEDIATRICS 

is  frequent.  To  the  pediatrist  the  usual  alopecia  areata  is  of  little  moment, 
since  in  the  young  the  hair  usually  grows  in  of  its  own  accord.  Particular 
attention,  however,  is  called  to  that  type  which  tends  to  become  universal 
with  the  loss  of  eyebrows,  eyelashes,  axillary  and  pubic  hair,  and  even 
lanugo  hair.  When  the  onset  of  such  a  condition  is  sudden,  it  is  more  than 
likely  to  be  permanent.  I  have  seen  a  number  of  such  cases,  have  attempted 
various  kinds  of  therapy  and  always  with  no  result.  In  no  case  in  my 
experience  has  a  general  examination  disclosed  anything  wrong.  In  the 
ordinary  case,  stimulation  with  alcoholic  lotions  or  application  of  ultra- 
violet rays,  hastens  the  growth  and  tends  to  insure  a  growth  of  the  normal 
colored  hair  instead  of  white  or  gray. 


BENIGN  EPITHELIAL  GROWTHS 

(ADENOMA  SEBACEUM) 

Adenoma  sebaceum  is  a  disease  characterized  by  the  development  on 
the  face  of  tumors  of  the  sebaceous  glands.    It  begins  in  early  childhood  as 


FIG.  302. — Adenoma  sebaceum.     (Courtesy  of  Richard  L.  Sutton.) 

bright  red,  yellowish  or  brownish  pinhead  to  pea-sized  papules  on  the  cheeks, 
forehead,  nose  and  chin.  The  color  is  due  to  minute  telangiectases.  There 
are  frequently  seen  in  conjunction,  moles,  naevi  and  other  developmental 
defects.  Patients  are  frequently  of  low  mentality.  The  lesions  persist, 
being  most  abundant  at  puberty.  Treatment  is  by  destruction  with  elec- 


EXUDATIVE  DERMATOSIS  843 

trie  needle  or  cautery.    Where  lesions  are  abundant,  I  have  had  good  re- 
sults from  freezing  thirty  to  forty  seconds  with  carbon  dioxide  snow. 


FIQ.  16. — Adenoma  sebaceom.     (Courtesy  of  H.  H.  Uazen.) 

HYPERTROPHIES 

(VERRUCA  VULGARIS) 

Verruca  vulgaris  or  common  wart  is  seen  almost  entirely  in  childhood. 
It  is  now  accepted  that  they  are  mildly  infectious  and  contagious,  although 
nothing  is  known  as  to  the  infecting  organism.  The  lesions  occur  chiefly 
on  the  hands  and  are  hypertrophic  epithelial  growths.  Of  the  many  caustics 
so  frequently  recommended  and  tried,  almost  all  are  to  be  condemned  as 
they  frequently  lead  to  infection  and  bad  scarring.  Magnesium  sulphate 
and  mercury  internally  have  been  reported  .as  successful.  The  former 
in  sufficient  dosage  to  produce  two  or  three  movements  of  bowels  daily 
and  the  latter  as  protiodid  in  proper  dosage  according  to  the  age.  I  prefer 
local  treatment.  Roentgen  ray  and  radium  applied  just  short  of  producing 
erythema  are  painless,  almost  invariably  successful  and  leave  no  scar.  The 
high  frequency  spark  is  successful  but  painful  and  children  will  scarcely 
stand  it.  CO2  snow  can  be  used  successfully  and  is  not  exceedingly  painful, 
the  lesion  is  pared  down  as  much  as  possible  and  an  area  larger  than  the 
wart  frozen  about  one  minute  with  good  pressure,  a  blister  results  with  the 
wart  on  top.  A  dressing  should  be  applied  to  prevent  infection  while  healing. 
Raying  is  particularly  to  be  advised  when  the  warts  occur  around  the  nails. 

VERRUCA  PLAN^E  JUVENILIS 

This  type  of  wart  is  seen  usually  in  infancy  and  childhood.  The  lesions 
are  flat,  numerous,  yellow  and  glistening  and  appear  chiefly  upon  the  face, 
neck  and  backs  of  the  hands.  They  are  very  small,  sometimes  barely  visible. 


844 


TEXT-BOOK  OF  PEDIATRICS 


This  is  the  type  in  which  the  internal  treatment  is  more  often  successful. 
Light  cauterizing  with  a  saturated  solution  of  trichloracetic  acid  or  the 
application  of  10  to  15  per  cent,  salicylic  acid  in  collodion  isusuallysuccessful. 

KERATODERMIA  PALMARIS  ET  PLANTARIS 

(SYMMETRICAL  KERATODERMIA  OF  THE  EXTREMITIES,  CONGENITAL  KERA- 
TOMA  OF  THE  PALMS  AND  SOLES,  ICHTHYOSIS  PALMARIS  ET  PLANTARls) 

Definition. — This  condition  is  a  familial,  often  hereditary,  symmetrical 
hyperkeratosis  of  the  palms  and  soles. 

Symptoms. — The  palms  and  soles  show  patches  of  thickened  epidermis 
up  to  an  eighth  or  quarter  of  an  inch,  which  are  smooth,  yellow  and  sharply 
marginated.  While  the  condition  is  often  hereditary,  it  may  not  appear 
for  a  number  of  years.  There  are  usually  several  cases  in  the  same  family. 

Course. — The  disease  is  permanent. 

Differential  Diagnosis. — Appearance  and  history  are  usually  sufficient 
to  assure  the  diagnosis.  A  similar  condition  may  appear  in  psoriasis  and 
arsenical  keratosis  must  be  considered. 

Treatment. — In  the  true  cases  treatment  is  palliative  only  and  consists 
of  the  application  of  oils  or  oily  salves.  Diachylon  ointment  applied  thick 
on  lint  serves  well.  X-rays  may  be  tried. 

ICHTHYOSIS 
(XERODERMA,  FISHSKIN  DISEASE) 

Ichthyosis  is  a  congenital  defect 
of  the  skin  characterized  by  harsh- 
ness, dryness  and  scaling,  due  to 
an  increase  in  the  horny  layer  and 
a  deficiency  of  the  secretions. 
While  ichthyosis  is  a  congenital 
defect  it  does  not  ordinarily  become 
apparent  until  the  second  or  third 
year,  thereafter  remaining  un- 
changed until  puberty  when  im- 
provement may  take  place.  There 
is  a  true  congenital  type  which 
occurs  very  rarely.  It  is  mani- 
fested at  birth,  the  surface  being 
covered  by  thick,  scale-like  plates 
marked  in  all  directions  by  fissures 
in  the  horny  epidermis.  The  skin 
is  immobile.  Such  cases  are  seen 
usually  in  children  prematurely 
born  and  they  usually  die  within  a 
few  days  from  inanition  or  loss  of 
heat.  It  is  usually  impossible  for 
FIG  17.— ichthyosis  (Harlequin  Fetus.)  them  to  nurse  on  account  of  im- 

(Courtesy  of  Richard  L.  button.) 


EXUDATIVE  DERMATOSIS  845 

mobility  of  the  lips.  A  condition  which  simulates  true  ichthyosis  is  due  to 
an  accumulation  of  vernix  caseosa,  which  continues  to  be  produced  for  a 
few  days  after  birth.  The  skin  is  encrusted,  tense,  fissured  and  of  a  brown- 
ish-red color.  These  cases  may  die  of  inanition  unless  the  crustations  are 
softened  and  removed  with  oily  applications  and  the  body  temperature 


— Ichthyosis.     (Courtesy  of  Richard  L.  Sutton.) 


artificially  maintained.  There  is  also  another  rare  condition  in  which  the 
child  is  born  with  a  membrane  covering  the  skin  which  resembles  collodion. 
This  peels  off  in  sheets  followed  by  further  desquamation  and  normal  skin. 
It  is  suggested  that  this  is  an  example  of  the  persistence  of  the  epitrichial 
layer  usually  cast  off  at  the  seventh  fetal  month. 

Ichthyosis  or  ichthyosis  simplex  is  a  general  condition  involving  the 
entire  skin  to  a  greater  or  less  degree,  while  ichthyosis  hystrix  is  limited  to 
irregular  circumscribed  areas.  The  condition  varies  in  intensity,  from  a 


846 


TEXT-BOOK  OF  PEDIATRICS 


slight  roughening  of  the  skin  to  cases  in  which  the  horny  epidermis  consists 
of  thick  plates,  resembling  fish  scales.  It  is  usually  worse  on  the  extensor 
surfaces  of  the  arms  and  legs.  The  hair  and  nails  are  usually  dry,  the  hair 
lustreless  and  the  nails  brittle.  There  are  no  subjective  symptoms  but  the 
condition  of  the  skin  makes  it  susceptible  to  certain  types  of  dermatitis,  due 
to  the  lack  of  secretions,  these  inflammations  are  more  likely  to  arise  in 


FIG.  19. — Ichthyosis. 

the  cold  weather.  The  affection  is  hereditary  and  frequently  more  than 
one  case  is  seen  in  a  family.  While  ichthyosis  cannot  be  cured,  the  patient 
can  be  greatly  benefited  with  proper  care.  Some  patients  show  thyroid  dis- 
turbance and  are  greatly  improved  by  thyroid  extract.  Not  more  than  a 
grain  a  day  should  be  given  to  start  with,  the  dose  to  be  increased  accord- 
ing to  tolerance. 

Proper  care  consists  of  a  daily  bath  and  inunction  with  a  bland  fat.  In 
severe  cases  tincture  of  green  soap  is  necessary  as  well  as  keratolytic  salves 
such  as  one  containing  salicylic  acid  5  to  10  per  cent. 


EXUDATIVE  DERMATOSIS 
ATROPHIES 


847 


(XERODERMA  PIGMENTOSUM) 

Xeroderma  pigmentosum  is  a  rare  disease  of  the  skin  beginning  in  early 
childhood,  occurring  in  families  and  characterized  by  the  appearance  of 


FIG.  20. — Xeroderma  pigmentoea.     (Courtesy  of  H.  H.  Hazen.) 

freckles  following  which  there  are  atrophic  changes  and  later  malignant 
growths.  The  disease  may  show  its  first  manifestation  by  erythematous 
spots  in  infancy  but  later  freckles  appear  becoming  more  numerous  and 
more  pronounced.  The  skin  in  a  few  years  takes  on  the  appearance  of 
extreme  age  with  atrophy,  a  waxy  drawn  appearance,  telangiectases  and 


848  TEXT-BOOK  OF  PEDIATRICS 

keratoses  appear  which  rapidly  become  malignant.  The  lesions  are  limited 
to  the  exposed  surfaces  and  aggravated  by  light.    It  is  undoubtedly  due  to 


FIG.  .21 — Xeroderma  pigmentosa.     (Courtesy 
of  Richard  L.  Sutton.) 

a  congenital  defect.  The  disease  usually  starts  in  the  first  year  or  two  and 
reaches  its  height  at  six  to  eight,  while  death  occurs  within  two  or  three  years 
with  frightful  distortion  and  disfigurement.  Occasionally  malignancy  does 
not  develop. 

DEGENERATIVE 
NEOPLASMATA 
MOLLUSCUM  CONTAGIOSUM 
(MOLLUSCUM  SEBACEUM, 
EPITHELIOMA  CON- 
TAGIOSUM) 

Molluscum  contagiosum 
is  a  disease  of  the  skin, 
with  small  epithelial  waxy 
rounded  tumors,  usually 
umbilicated  and  multiple 
in  number.  While  the 
disease  is  rather  uncommon 
it  occurs  more  frequently 
in  children  than  in  adults 
and  particularly  in  those 
of  the  poorer  class,  or  in 
institutions.  There  are 
usuaUy  from  two  or  three 
to  a  dozen  lesions  and  these 
are  seen  most  frequently 
on  the  face,  eyelids,  nose, 
scrotum  or  backs  of  the 

PIG.  22. — Molluscum  contagiosum.  (Courtesy  of  Howard  Fox.) 


EXUDATIVE  DERMATOSIS  849 

hands.  The  lesions  usually  remain  separate,  but  may  group,  each  remain- 
ing distinct.  They  are  usually  the  size  of  a  pinhead  or  a  small  pea  but  on 
rare  occasions,  lesions  an  inch  or  two  in  diameter  are  seen.  Individually 
the  tumor  is  distinctly  raised,  constricted  at  the  base,  almost  peduncu- 
lated,  waxy  in  appearance  and  umbilicated  with  an  opening  in  the  umbili- 
cation  from  which  cheesy  material  may  be  expressed.  They  are  mildly 
infectious  but  the  organism  is  not  known.  The  characteristic  lesions  offer 
little  difficulty  in.  diagnosis.  Untreated  they  tend  to  persist  mouths  or 
even  years.  Treatment  consists  of  puncture  and  expression  of  the  con- 
tents. Usually  a  puncture  which  draws  blood  is  sufficient  without  expression. 

XANTHOMA 
(FIBROMA  LIPOMATODES,  XANTHELASMA) 

Xanthoma  multiplex  (xanthoma  tuberosum)  is  a  rare  disease  but  may 
occur  in  children.  The  lesions  are  rather  rounded,  pea  to  bean-sized,  from  a 
yellowish  to  a  brownish-red  in  color  and  when  seen  in  children  are  usually 
multiple  and  general  in  distribution.  They  are  usually  rather  hard  and 
once  formed  persist  with  practically  no  subjective  symptoms.  Only  radical 
treatment  is  successful,  the  cautery  or  strong  (25  per  cent,  to  4  per  cent.) 
salicylic  acid  either  in  plaster  or  collodion. 

NEVUS 
(BIRTH-MARK) 

There  are  two  kinds  of  nevi,  pigmented  and  vascular.  The  former  are 
frequently  classified  among  skin  hypertrophies  and  the  latter  among  tumors 
of  blood-vessels.  Since  the  podiatrist  is  concerned  only  with  types  and 
little  with  the  diseases  sometimes  classified  with  blood-vessel  disturbances, 
it  seems  more,  practical  to  consider  all  nevi  under  one  heading. 

NEVUS  PIGMENTOSUS 
(PIGMENTED  MOLE) 

Pigmented  nevi  are  circumscribed  lesions  of  the  skin  in  which  there  is 
increased  pigmentation.  They  may  or  may  not  be  covered  with  downey  or 
coarse  hair.  The  lesions  more  often  appear  on  the  face,  neck,  trunk,  thighs, 
buttocks  and  genitalia,  but  may  appear  anywhere.  They  vary  in  size  and  • 
shape  and  may  be  smooth  and  flat  or  raised  and  warty.  Their  occurrence 
may  be  single  or  multiple  and  disseminated  or  grouped.  They  are  rarely 
found  at  birth  but  make  their  appearance  during  infancy.  No  subjective 
symptoms  are  present.  There  is  no  tendency  to  spontaneous  disappearance. 
Pigmented  nevi  or  moles  are  important  for  two  reasons,  first  cosmetic  and 
54 


850 


TEXT-BOOK  OF  PEDIATRICS 


FIG.  23. — Nevus  pigmentary.     (Courtesy  Richard  L.  Sutton.) 


Fia.  24. — Nevus  pigmentary.     (Courtesy  of  Howard  Fox.) 


EXUDATIVE  DERMATOSIS  851 

second  on  account  of  their  well-known  tendency  to  malignancy,  the  pediat- 
rist  is  not  concerned  with  the  latter  as  malignant  changes  rarely  occur 
before  forty. 

Treatment. — Small  brown  moles  may  be  removed  by  fulguration  or 
electric  needle.  With  the  exception  of  trichloracetic  acid,  no  acids  or  other 
caustics  should  be  used  on  account  of  the  danger  of  unnecessary  scarring. 
The  small  lesions  may  easily  be  removed  by  painting  lightly  with  a  solution 
of  trichloracetic  acid,  almost  no  scarring  results  and  I  have  never  seen  any 
hypertrophic  scars  follow  its  use,  such,  as  are  frequently  seen  after  nitric 
acid.  The  solution  should  be  made  by  adding  just  enough  water  to  the 
crystals  to  dissolve  them.  The  dark  blue  or  black  moles  should  not  be 
interfered  with  except  in  the  most  radical  manner  since  danger  of  malig- 
nancy is  great  and  when  it  occurs  it  is  usually  widely  disseminated  and 
incurable.  The  larger  lesions  may  be  treated  with  electric  needle  and  hairs 
removed  by  the  same  agent.  Freezing  from  twenty  to  sixty  seconds  with 
carbon  dioxide  snow  is  successful.  Th6  X-ray  skilfully  used  will  give  a  good 
result,  trial  by  any  one  but  an  experienced  therapeutist  is,  however,  not  to  be 
recommended.  Radium  is  less  dangerous.  Excision  does  not  give  as 
satisfactory  results  as  the  other  methods  mentioned. 

NEVUS  VASCULOSUS 

(NEVUS  SANGUINEUS,  NEVUS  FLAMMEUS,  MOTHS  MARK,   BIRTH-MARK> 

PORT- WINE-MARK) 

A  vascular  nevus  is  a  congenital  hyperplasia  of  the  cutaneous  vascular 
system.  These  nevi  may  be  flat  or  raised,  single  or  multiple,  large  or  small 
with  the  color  depending  upon  their  structure.  There  are  three  types  of 
vascular  nevi. 

First,  flat  nevi  consisting  merely  of  dilated  capillaries  (the  port-wine- 
mark)  . 

Second,  hypertrophic  nevi,  angiomata  made  up  of  a  net-work  of  large 
dilated  vessels. 

Third,  angioma  cavernosum,  a  cavernos  nevus  which  usually  enlarges. 

The  color  in  all  types  depends  upon  whether  the  blood  is  arterial  or 
venous.  They  are  usually  sharply  circumscribed  and  compressible.  More 
frequently  these  nevi  appear  on  the  face,  head  or  neck,  but  no  part  of  the 
body  is  exempt.  Flat  or  hypertrophic  nevi  may  be  present  at  birth  or  make 
their  appearance  shortly  after,  they  usually  increase  in  size  for  a  time  and 
then  remain  fixed.  The  large  angiomata  sometimes  ulcerate  following 
trauma  and  a  cure  results.  There  is  of  course  in  such  a  case  definite 
danger  of  alarming  hemorrhage.  Other  than  this  there  is  no  tendency  to 
spontaneous  disappearance.  Most  nevi  are  amenable  to  treatment.  The 
raised  ones  may  be  frozen  with  CC>2  snow  ten  to  thirty  seconds,  flat  ones  do 
not  respond  to  this.  The  flat  type  may  be  treated  with  the  Kromayer 
quartz  lamp  (ultra-violet  light).  This  and  other  types  may  be  treated  with 


852 


TEXT-BOOK  OF  PEDIATRICS 


FIG.  25. — Angioma.     (Courtesy  of  Howard  Fox.) 

radium  or  X-ray;  in  either  case  inasmuch  as  the  cosmetic  result  is  usu- 
ally of  great  importance,  the  work  should  be  attempted  only  by  one  who 
is  experienced. 

TELANGIECTASIS 

Telangiectases  are  acquired  dilated  capillaries.  There  may  be  many  or 
few  and  they  are  usually  seen  on  the  face.  They  frequently  occur  in  the 
form  of  a  central  red  dot  with  radicating  dilated  capillaries  constituting 
the  so-called  spider  nevus  or  nevus  araneus.  These  may  be  treated  by  using 
the  electric  needle,  with  one  and  one-half  milliamperes  of  current,  the 
negative  pole,  in  the  central  dot.  On  account  of  the  pain  with  small  children 
it  is  easier  to  use  a  needle  cautery  and  just  lightly  puncture  at  the  point. 


INDEX 


A.  C.  INTERVAL,  390 

Abdomen,  examination  of,  79 

pendulous,  in  rickets,  192 

tenderness  in,  localized,  to  pressure,  79 
Abdominal    pains   in   intestinal    tubercu- 
losis, 320 

strain,  676 

wall,  79 

emaciation  of,  79 
laxity  of,  79 

peristaltic  waves  seen  in,  79 
Abortion  in  syphilis,  755 
"Absences,"  538,  545,  548,  557 
Abscess  of  brain,  496 

retropharyngeal,  252 
Abscesses  in  meningococcus  meningitis,  471 

in  sepsis,  of  new-born,  146 

of  liver  from  lymphangitis  of  umbilical 

vein,  141 

Acarus  scabiei,  816 
Accomodation  reaction,  33 
Acetanilid,  hemocytolysis  from,   166 
Acetone  bodies  in  urine,  due  to  disturbance 
of  fat  metabolism,  18 

incombustible  end-product,  23 

odor  in  acute  dyspepsia,  307 
Acetonemic  vomiting  in  arthritism,  222 
Acetphenitidin,  hemocytolysis  from,  166 

in  meningococcus  meningitis,  473 
Acetylsalicylic  acid  in  fever,  107 
Achondroplasia,  236 

nose  in,  347 
Acidity  test  for  milk,  56 

Soxhlet-Henkel's,  56 
Acidosis  in  alimentary  intoxication,  295 

in  diabetes  mellitus,  208,  209 
Acne    albida,    840 

neonatorum,   840 

scrofulosum,  823 

vulgaris,  840 
Activation  of  one  infectious  disease  by 

another,  577 
Acute  dyspepsia,  289,  307 

infectious  diseases,  Part  VIII,  p.  571 

internal  hydrocephalus,  458 
Adenoma  of  umbilicus,  139 

sebaceum,  842 
Adenoiditis,  250 

breathing,  nasal,  in  250 

pharyngitis,  superior,  in  250 
Adenoids,  252,  353 

examination  for,  74 
Adhesions,  pericardial,  411 
Adiposis,  210 
Adiposo-genitalis,  235 
Adolescence,  weight  increase  in,  26 

height  increase  in,  26 
Adrenals,  tumors  of,  456 


Adult,  differences  from  new-born  infant,  1 

water  contents  of,  1 

Aerobic  bacteria  in  breast-fed  children,  12 
Affekt-epilepsie,  548 
Agglutination  test  in  dysentery,  316 
in  paratyphoid,  699 
in  tuberculosis,  699 
in  typhoid  fever,  695 
Air,  action  of,  in  changing  color  of  stools,  11 
Air  passages,  upper,  tuberculosis  of,  729 
Albuminuria  of  new-born,  12,  154 

orthotic,  421 
Alcohol,  abuse  of,  117 
in  collapse,  108,  109 
in  erysipelas,  149 
in  fever,  to  be  avoided,  107,  109 
in  fissure  of  nipples,  38 
in  milk,  presence  of,  42 
in  nursing  women,  42 
in  stomachics,  117 
use  of,  117 

Alcoholism,  obesity  from,  in  children,  210 
Aleucemic  lymphadenosis,  184 
Alkalis  in  arthritism,  222 
Allaitement  mixte,  49,  54 
Allergy  in  tuberculosis,  722 
Alimentary  anemia,  161,  170,  171,  172 

treatment  of,  172 
fever,  262,  263,  292,  301 

treated  by  water  diet,  106 
intoxication,  291,  300 
acidosis  and,  295 
albuminuria  in,  292,  293 
baths  in,  297 
boxer's  position  in,  292 
brandy  in,  297 
breast-milk  in,  297 
butter-milk,  in  298,  299 
overfeeding  of,  in,  296 
caffein  in,  297 
camphor,  digalen  in,  297 
casts  in,  292 

cataleptic  condition  in,  292 
cause  of,  295 
cerebral  type  of,  294 
chloral,  danger  of,  in,  297 
cholera,  resemblance  to,  294 
nostras,  similarity  to,  294 
choreiform  type  of,  294 
"coffee  grounds"  vomited  in,  293 
cold  packs  in,  297 
collapse  in,  292,  293 
colon  washed  in,  297 
coma  in,  292 
convulsions  in,  292 
decomposition  and,  291 
dehydration  in,  296 
detoxicated  salt  solution  in,  297 
853 


854 


INDEX 


Alimentary  intoxication,  detoxication  in, 
295,  296 

diagnosis  of,  296 

differential,  from  sepsis  of  new-born, 
146 

diarrhoea  in,  292 

dyspeptic  stools  in,  292 

dystrophy  and,  291 

epinephrin  in,  297 

etiology  of,  295 

fermentation  products  in,  294 

fever  in,  292 

food,  withdrawal  of,  in,  296 

gastric  hemorrhage  in,  293 

glycosuria  in,  292,  293 

Heim-Johns'  solution  in,  296 

hemorrhage  in,  293 

"hunted  beast"  respiration  in,  292 

hydrocephaloid  type  of,  294 

hyperacidity  of  tissues  in,  294 

leucocytosis  in,  292,  293 

Mary's  vegetable  bouillon  in,  297 

metabolism  and,  295 

milk,  skimmed,  in  298 

Moro's  carrot  soup  in,  297 

mucus  in  stools  in,  293 

muscular  hypertonicity  in,  293 

mustard  bath  in,  297 

narcotics  in,  297 

organisms  in,  294 

osmosis  in,  295 

packs,  cold,  in,  297 

paralysis  in,  292 

physiologic  salt  solution  in,  296 

pituitrin  in,  297 

polycythsemia  in,  293 

prognosis  of,  296 

protein,  toxic  action  of,  in,  295 

pulse  in,  293 

pyrexia  in,  292 

respirations  in,  292 

saccharin  in,  296 

salt  solution  in,  296,  297 

sclerema,  fat,  in  293 

sighing  respiration  in,  292 

skimmed  milk  in,  298 

skin  in,  293 

sodium  diethylbarbituate  in,  297 
salts,  toxic  action  of,  in  295 

soporific  type  of,  294 

stomach  washed  in,  297 

subcutaneous  injections  of  salt  solu- 
tion in,  297 

subfebrile  temperature  in,  292 

sugar,  toxic  action  of,  in,  295 

sugars  in  urine  in,  293 

symptoms  of,  292 

tea  in,  296 

"toxic  breathing"  in,  292 

treatment  of,   296 

types  of,  294 

urine  in,  293 

veronal  in,  297 

vomiting  in,  293 

washing  of  stomach  and  colon  in,  297 


Alimentary  intoxication,  weight-curve  in, 

292,  293,  296,  298 
whey  in,  298 
whole  milk  mixture  in,  298 

toxicosis,  291 
Alopecia  areata,  841 
Alterants,  empiric  use  of,  117 
Altitude,  high,  in  treatment  of  anemia,  174 
Alveolus,  necrosis  of,  247 
Aluminum  acetate,  114 
Amaurotic  familial  idiocy,  523 

juvenile,  523 

Amboceptors,  autolytic,  166 
Amentia,  570 

Amenorrhcea  during  lactation,  43 
American  Child  Hygiene  Association,  91 
Amino-acids,  10,  15 
Amnion  navel,  134 

Amniotic  fluid  in  air  passages  of  asphyx- 
iated child,  126 
in  middle  ear,  356 
Amphoteric  reaction  of  milk,  4,  5 
Amyolytic  secretion  of  pancreas,  18 
Amyotrophic  lateral  sclerosis,  528 
Amyotrophy,   infantile   progressive,    mis- 
taken for  rickets,  204 
Anaerobic  organisms  in  breast-fed  infants, 

12 

Anal  region,  cleansing  of,  in  girls,  67 
Analeptics  in  meningitis,    473 
Anaphylato  toxin,  805 
Anaphylaxis  in  diphtheria,  665 
Anatomic    and    physiologic    peculiarities, 

Chapter  I,  p.  1 

Anchylostomata,  hemic  poison  from,  167 
Anemia,  alimentary,  161,  170,  171,  172 
toxic  type  of,  162 

treatment  of,  172 

altitudes,  high,  in  treatment  of,  174 

anergic,  early  acquired,  161 
type  of,  treatment  of,  173 

aplastic  type,  161 
treatment  of,  173 

artificial  sunlight  in,  174 

auto  transfusion  in  treatment  of,  174 

Banti-Senator,  form  of,  171 

Biermer  type  of,  167,  168 

bleeding  in  treatment  of,  173 

blood,  loss  of,  causing,  164 

bone-marrow  in  treatment  of,  173 

camp  life  in  treatment  of,  174 

chlorotic,  161 

compensatory,    160 

complicating,  167 

congenital,   161 

Czerny's  treatment  of,  170,  171,  173 

from  animal  parasites,  165 

from  epistaxis,  165 

from  umbilical  hemorrhage,  165 

Gaucher's  splenomegaly,  form  of,  172 

hemocytolytic,   165 

in  Barlow's  disease,  165 

in  hemorrhagic  diathesis,   165 

in  infantilism,  161 

in  melena,  165 


INDEX 


855 


Anemia,  in   myxedema,   congenital,  form 
of,  161 

in  nephritides,  hemorrhagic,  165 

in  nephroses,  chronic,  167 

in  polyposis,  rectal,  165 

in  premature  children,  125 

in  rickets,  162,  169,  170 

in  syphilis,  167,  771 
treatment  of,  172 

incubator,  162 

intramuscular    injection    of    blood     in 
treatment  of,  174 

iron  in  treatment  of,  172 

v.  Jaksch-Hayem,  168 
treatment  of,  173 

leucanemic  type,  168 

light,  effect  of,  on,  162,  174 

meat  juice  in  treatment  of,  173 

myelopathic,  165 

organotherapy  of,  173 

oxygen-poor  air  in  treatment  of,  174 

parasitic,  treatment  of,  172 

pernicious  type  of,  167,  168 
treatment  of,  173 

"physical"  treatment  of,  174 

post-hemorrhagic,  164,  165 

poverty,  162,  170 

pseudo-,   174 

pseudoleucemic  infantile,  168,  170 

psychic  traumata  causing,  175 

rare  forms  of,  171 

regenerative  tvpe  of,  168 

school,  162,  163 

secondary,  167 

sun-baths  in  treatment  of,  174 

tachycardia  in,  159 

tenement,  162 

toxic,  alimentary  type,  of,  162 
treatment  of,  172 

toxogenous,  166,  167,  171 

transfusion  in  treatment  of,  173 

traumatic,  164 

tropho  toxic,   170 
treatment  of,  173 

tuberculosis  accompanying,  162,  167 

umbilical  hemorrhage  causing,  165 

X-rays  in  treatment  of,  174 
Anemias,  group  of,  159 

symptomatology,  general,  159 

due  to  primary  interference  with  ery- 

thropoiesis,   161 

Anencephalic  infants,  taste  in,  33 
Anergic-aplastic  anemia,  treatment  of,  173 
Anesthesin  ointment  for  fissured  nipples, 

38 
Anesthesia,  dangers  of,  in  status  thymico- 

lymphaticus,  217 
Aneurism  of  aorta,  417 
Angina,  a  bacitte  fusiform,  251 

bacterial  origin  of,  249 

catarrhal,  249 

chancriform,  252 

complications  of,  250 

definition  of,  248 

diphtheroid,  Plaut's  251 


Angina,  etiology  of,  249 
exudative,  249 
faucial  tonsil  in,  249 
follicular,  249 
gangrenous,  252 
lacunar,  249 

differentiated  from  diphtheria,  656 
lymphatic  ring  in,  248 
palatal,  249 
pharyngeal,   250 
Plaut's  diphtheroid,  251 
retronasal,  249,  250 

in  meningococcus  meningitis,  467 
scarlatinal,    to    be  differentiated    from 

diphtheria,  656 

without  skin  eruption,  249,  588 
Vincent's,  251 

differentiated  from  scarlatina,  656 
Angiospasm,  cuticular,  175 
Angiospastic  dysuria,  426 
Anilin  derivatives,  hemocj'tolysis  from,  166 
Anions,  18 

Anisocytosis,  163,  164 
Ankle  clonus,  81 
Anorexia  in  children,  212 

in  tuberculous  meningitis,  459 
nervous,  328 
treatment  of,  117 
Anomalies,  constitutional,  Part  II,  p,  156; 

213,  214,  261 

Antenatal  protection  of  child,  98 
Antibodies  in  tuberculosis,  735,  737,  738 
Antifebrin,  hemocytolysis  from,  166 
Antiformin  method,  737 
Antimeningococcic    serum     in     meningo- 
coccus meningitis,  473 
Antimony  in  acute  dyspepsia,  308 
Antipyretics  in  fever,  107 
Antipyrin  in  fever,  107 

in  meningococcus  meningitis,  473 
Antirickitic  vitamin,  19,  207 
Antiscorbutic  vitamin,  19 
Antistreptococcic  serum  in  sepsis,  148 
Antitetanic  serum,  143 
Antitoxin,  diphtheritic,  dose  of,  661 
immunity,  unit  of,  661 
intravenous,  injection  of,  662 
method  of  preparing,  661 
mortality  after  use  of,  663 
prophylactic,  dose  of,  661 
time  to  use,  667 
Antityphoid  vaccination,  696 
Antivaccinationists,  631,  635,  637 
Aorta,  aneurism  of,  417 
Aortic  insufficiency,  405 

stenosis,  399,  405 
Aortitis,  417 

Ape-man  type,  reversion  to,  238 
Apex  beat,  situation  of,  75 
Aphthae,  Bednar's,  67 
Apices  of  lungs,  examination  of,  in  tuber- 
culosis, 735 
in  chronic  pulmonary  tuberculosis, 

735 
Aplastic  anemia,  168 


856 


INDEX 


Apncea,  expiratory,  in  spasmophilia,  534 
Apoplexia  serosa  in  serous  meningitis,  474 
Apotoxins  in  tuberculosis,  738 
Appendicitis,  peritonitis,  in,  341 

opium  in,  115 

Appetite,  loss  of,  in  acute  dyspepsia,  307 
Arc  de  cercle  in  meningococcus  meningitis 

469 

Areola  in  sucking,  44 
Argyrol  in  ophthalmia  neonatorum,  151 
Arhythmia  of  heart,  390 
Arm,  paralysis  of,  528 
Aromatic  tinctures,  117 
Arsenic  in  anemia,  173 
in  myelo-cytomatosis,  183 
in  purpura  hemorrhagica,  185 
poisonous  action  on  blood,  167 
tonic  action  of,  116 
Arsphenamin    products   in    treatment   of 

syphilis,  783 

Arterio-sclerosis  almost  unknown  in  child- 
hood, 2,  417 

Arthritis,  hemorrhagic,  185 
gonorrheal,  150 
pneumococcic,  710 
Arthritism,  anemic  type  of,  221 
Bouchard's  brady trophy  in,  221 
definition  of,  221 
erethismic  type  of,  221 
habitus  of,  221 
in  childhood,  221 
obese  type  of,  221 
plethoric  type  of,  221 
treatment  of,  224 

uric  acid  diathesis  of  adults  and,  221 
urine  in,  222 
Arthrogryposis,  536 
Articular  rheumatism,  acute,  706 
age  in,  706 
angina  in,  706 

causative  organism  unknown,  706 
cerebral  symptoms  in,  709 
chorea  in,  706 
constitutional  disturbances  found  in, 

706 

definition  of,  706 
diagnosis  of,  709 

differential,  709 
from  infantile  scurvy,  709 
from  rickets,  709 
from    syphilitic    osteochon- 

dritis,   709 

duration  of  attack  in,  708 
endocarditis  in,  707,  708, 
erythemata  in,  709 
fever  in,  707 
heart  complications  in,  706, 707,  708 

murmurs  in,  707,  708 
heredity  in,  706 
infectious  agent  in,   706 
joint  affections  in,  706,  707 
nodular,  709 

pericarditis  in,  707,  708,  709 
pleurisy,  fibrinous  in,  709 
predisposition  in,  706 


Articular  rheumatism,  acute,  prognosis  of, 

710 

relapses  in,  708 
salicylates  in,  710 
scarlatinal,  710 
sweats  in,  707 
treatment  of,  710 
tuberculous,  710 
Artificial  feeding,  54 

caloric  values  in,  62 
dangers  from,  54,  98,  103 
disturbance  of  nutrition  in,  256 
improvement  of  methods  in,  104 
increased  death-rate  in,  90 
sepsis  in,  145 

statistics  of,  90,  91,  92,  93,  94,  95,  96 
technic  of,  58 

foods,  dangers  from  using,  103 
use  of,  in  older  children,  117 
light  in  treatment  of  rickets,  206 
Ascaris  lumbricoides,  167,  337 
Ash  of  milk,  4,  5 
Asiatic  cholera,  315 
Asphyxia,  congenital,  125 
in  intubation,  669 
livida,  125 
of  new-born,  125 

autopsy  findings  in,  126 

causes  of,  125 

cerebral  hemorrhage  in,  126,  129 

death-pallor  variety  of,  125 

definition  of,  125 

heart-massage  in,  126 

hemorrhagic  diseases  arising  from, 

126,  129 

livid  variety  of,  125 
prognosis  of,  126 

rhythmic  traction  of  tongue  in,  126 
Schultze's  method  of  resuscitation 

in,  126 

symptoms  of,  125 
therapy  for,  126 
pallida,  125 

postnatal,  acquired,  125 
causes  of,  126 
diagnosis  of,  127 
oxygen  in,  127 
prognosis  of,  127 
symptoms  of,  127 
treatment  of,  127 

Aspidium,  ectogenous  blood  poison,  166 
Aspiration  in  cerebral  hemorrhage,  130 
Asses 's  milk,  4 

low  fat  content  of,  4 
Asthmatic  dyspepsia,  308 
Astringents,  aluminum  acetate,  114 
bismuth,  subnitrate,  114 
oxide,  colloidal,  114 
subsalicylate,  114 
diacetylic  tannic  acid,  114 
tannalbin,  114 
tannigen,  114 
tannin,  113 
tannoform,  114 
starch  enemata  as  a  vehicle  for,  114 


INDEX 


857 


Asyla  for  children,  104 
Ataxia,  acute  cerebral  494 

Freidreich's  525 

hereditary,  525 

static,  525 
Atelectasis,  pulmonary,  of  new-born,   126, 

127 

Athetosis,  bilateral,  506 
Athyre9sis,  226 
Atrophies,  muscular,  526 

infantile  progressive  spinal,  526 

of  skin,  847 
Atrophy  9f  optic  nerve  in  menmgococcus 

meningitis,  471 

Atropin    for  vomiting    in  meningococcus 
meningitis,  473 

in  exudative  diathesis,  219 

secreted  in  milk  of  animals,  42 
Auditory  canal,  examination  for  pain  in,  75 
external,  examination  of,  355 
foreign  bodies  in,  360 

nerve,  medullation,  at  birth,  32 
Aura  in  epilepsy,  545 
Auricular  flutter,  390 

origin  of  paroxysmal  tachycardia,  390 
Auriculoventricular  block,  391 
Auscultation  of  lungs,  77,  78 
Autolytic  ambqceptors,  166 
Automatic  motions  of  new-born,  33 
Autoserum  in  purpura  hemorrhagica,  185 
Autotransfusion  in  anemia,  174 
Azotemia,  421 

BABINSKI'S  phenomenon,    physiologic    to 

second  year  of  life,  34 
Bacillus  acidophilus,  12 
bifidus  communis,  12 
butyricus,    12 
mobilis,  12 
coli  communis,  12 
in  sepsis  of  new-born,  144 
lactis  aerogenes,  12 
of  hemorrhagic  septicemia  in  sepsis  of 

new-born,   144 
of     tetanus,    finding    of,    in    umbilical 

wound,  142 

of  tuberculosis,  bovine  type,  720 
demonstration  of,  737 
discovery  of,  720 
finding  of,  735 
human  type,  720 
invasion  of  body  by,  720,  721 
of  whooping-cough,  671 
paratyphosus  A,  698 

B,  698 

perfringens,  12 
putrificans,  12 

pyocyaneus  in  sepsis  of  new-born,  144 
typhosus,  688 

Back,  drawing  pains  of,  relief  of,  42 
Backache    in    meningococcus    meningitis, 

468 

Bacteria,  intestinal,  value  of,  12 

Bacterial  contents  of  bowel,  12 

flora  of  digestive  tract,  12 


Bacterial  poisons,  absorption  of,  295 

Balance,  disturbance  of,  264 

Balanitis,  452 

Balanoposthitis,  452 

Balsam    Peru    in    treatment    of    fissured 

nipples,  38 

Banti-Senator  symptom-complex,   171 
Barley  in  infant  feeding,  61 
Barlow's  disease  (see  infantile  scurvy),  186 
Basedowoid  disease,  infantile,  235 
Basedow  's  disease,  235 
Basilar  meningitis,  458 
Basophilic  leucocytes  in  children,  2 
Baths,  daily,  66 

dangers  from,  in  institutions,  136 
for  premature  child,  121 
in  alimentary  intoxication,  297 
in  fever,  easy  application  of,  106 
in  insomnia,  115 
in  purulent  meningitis,  461 
in  sepsis,  148 
in  serous  meningitis,  476 
mustard,   108 
of  new-born,  66 

rectal  temperature  to  be  taken  in  judg- 
ing effects  of,  106 
sea-salt  for,  118 

skin  temperature  in,  misleading,  106 
temperature  of,  66 
Bednar's  aphthae,  67 

from  meddlesome  care  of  mouth,  145 
in  catarrhal  stomatitis,  242 
Bed-sores  in  tuberculous  meningitis,  462 
Bed-wetting,  447 

Bee  stings,  ectogenous  blood  poison,  166 
Beer,  caloric  value  of,  210 

effects  of,  on  nursing  mother,  42 
Behring's  diphtheria  vaccine,  666 
Benzol  in  myelo-cytomatosis,  183 
Benzosulphinidum,  290 
Beriberi,  a  food  disease,  19 
Berlin,  mortality  and  morbidity  statistics 

of,  before  the  war,  90 
Biedert's  natural  cream  mixture,  59 
Biermer  type  of  anemia,  167,  168 
Bier's  hyperemia  in  articular  metastases, 

151 

Bilateral  athetosis,  506 
Bile-ducts,  congenital  obstruction  of,  340 
course  of,  341 
symptoms  of,  341 
Bilirubin,  11 
formation  of,  166 
in  blood,  152 

in  tissues  in  icterus  neonatorum,  151, 152 
in  urine  in  icterus  neonatorum,  151 
Biliverdin,    11 

Birth,  asphyxia  at  and  after,  125,126,  127 
cranial  nerves  at,  32 
injuries  causing  tonic  contractions,  143 

increasing  death-rate,  95 
statistics,  Chapter  IV,  p.  86 
traumata,  127,  499 

causing  asphyxia  of  new-born,  126 
weight  at,  23,  24,  25 


858 


INDEX 


Birth-mark,  849 

Birth-rate,  relation  to  death-rate,  86 
Births  exceeding  deaths  per  1000  inhabi- 
tants of  various  countries,  86 
live,  proportion  of,  86 
per  1000  inhabitants,  86 
Bismuth  subgallate  for  fissured  nipples,  38 
for  treating  umbilical  wound,  66,  136 
subnitrate,  astringent  action  of,  114 
subsalicylate,  astringent  action  of ,  114 
oxide,  colloidal,  astringent  action  of,  114 
Black  salve,  composition  of,  38 

in  treatment  of  fissured  nipples,  38 
Bladder,  urinary,  catherization  of,  80 
control  of,  68 

cystoscopic  examination  of,  80 
infection,    dangers   of,    from   passing 

catheter,  80 

location  of,  in  infants,  13 
tuberculosis    of,    tuberculin    reaction 

in,   741 

Blaud's  pills  in  chlorosis,  173 
Bleeding  in  treatment  of  anemia,  173 
time  in  cephalhematoma,  128 
in  cerebral  hemorrhage,  130 
in  internal  hemorrhage,  130 
in  melena,  prolonged,  149 
in  umbilical  hemorrhage,  144 
Blennorrhoea,  chlamydozoa,  150 
inclusion  of  epithelium  in,  150 
of  umbilical  wound,  135,  136,  137 
Blindness  from  ophthalmia    neonatorum, 

150 

in  meningococcus  meningitis,  471,  473 
in  purulent  meningitis,  466 
Blinking  reflex,  33 
Blisters,  fever,  826 
Blood,  circuit  of,  more  rapid  in  children 

than  in  the  adult,  2 
collection  of,  for  examination,  85 

cupping  glass  method,  85 
compensatory  changes  in,  159 
crisis,  164 
in  childhood,  157 
in  infantile  scurvy,  188 
in  lymphatic  leucemia,  178 
in  meningococcus  meningitis,  469 
light,  effect  of,  on,  163 
oxygen  in,  159 

pathological  changes  of,  Part  II,  p.  156 
proportion  of,  to  body-weight,  163,  164, 

165 

retrograde  changes  in,  156 
specific  gravity  of  blood  in  new-born,  2 
total  volume  of,  determination  of,  175 
whole,  injected  in  cerebral  hemorrhage, 

130 

Blood-cells,  groups  of,  157 
Schridde's  table  of,  158 
Blood-forming  organs,  pathological  changes 

of,  Part  II,  p.  156 
Blood-platelets  reduced  in  purpura  hemor- 

rhagica,  184 
Blood  poisons,  165 
acetanilid,  166 


Blood  poisons,  anilin  derivatives,  166 

acetphenitidin,  166 

anchylostomata,    161 

antifebrin,  166 

arsenic,  167 

ascarides,    167 

aspidium,  166 

bacterial  poisons,  167 

bee  stings,  166 

bothriocephalus,    167 

burns,  166 

carbon  monoxide,  166 

ectogenous,  166 

endogenous,  166 

hydrogen  sulphide,  166 

hydrocyanic  acid,  166 

lactophenin,  166 

lead,  167 

lipoid  tissues,  167 

malaria,  166 

mercury,  167 

mushrooms,  166 

nephroses,  167 

phenocoll,  166 

phenol,  166 

phenolphthalein,  166 

potassium  chlorate,  166 

pyrogallol,  166 

scarlet  fever,  166 

sepsis,  166 

sera,  166 

snake  venom,  166 

solanum,   166 

syphilis,  167 

tenia,  167 

toxins  of  acute  intestinal  diseases,  167 

trichocephalus,  167 

tuberculosis,  167 

typhoid  fever,  166 

vegetable,  166 

Winckel's  disease,  166 
Blood-pressure,  age  average  of,  419 
increased,  419 
slight  value  of,  77 
Blood-sugar,  amount  of,  18 
Blood-vessels,  diseases  of,  417 
Blood-volume  per  minute,  159 
Bodily  needs,  care  of,  68 
Body  surface,  carbon  dioxide  excretion  in 
proportion  to,  20 

relation  to  body  weight,  14,  20,  21 
temperature  of  infant,  14 
Body-weight,  calories  per  pound  of,  64 
carbohydrates  metabolized  per,  64 
compared  with  that  of  nervous  system, 

31 

fat  metabolized  per,  64 
of  new-born  in  relation  to  surface,  14, 

20,21 

protein  metabolized  per,  64 
relation  to  amount  of  food  taken,  47,  59 

to  body  surface,  21 
Bolus  alba,  114 

for  mummification  of  umbilical  stump, 
66 


INDEX 


859 


Bolus  alba,  sterilized,  for  treating  umbilical 

wound,  136 
Bone-marrow,  hormone  of  spleen,  action 

of,  on,  167 
in  rickets,  192 
in  treatment  of  anemia,  173 
lead,  action  of,  on,  165 
Bones,  in  rickets,  196 
in  scrofula,  731,  734 
new  formation  of,  196 
ossification  of,  in  wrist,  29 
poisons,  action  of,  on,  167 
tuberculosis  of,  728 
Bordet  and  Gengou  's  bacillus,  672 
Bothriocephalus,  hemic  poison,  167 
Bottle-milk,  time  to  stop  giving,  52 

abuse  of  feeding  by,  52 
Bottles,  hot-water,  in  subnormal  tempera- 
tures, 108 

dangers  from  scalding  with,  108 
Botulism  from  thyroid  preparations,  234 
Bouchard's  bradytrophy,  221 
Bowels,  bacterial  contents  of,  12 
control  of,  68 

irrigation  of,  with  tannin,  113 
" Boxer's  position"  in  intoxication,  292 
Boys,  weight  increase  of,  26 
Brachial  plexus,  paralysis  of,  131 
atrophy  from,  131 
causes  of,  131 
contractures  from,  131 
diagnosis  of,  132 
electric  treatment  of,  133 
Erb'stypeof,  131 
flail-joint  from,  132 
forearm  type  of,  131 
Klumpke  s  type  of,  131 
reaction  of  degeneration  follow- 
ing, 132 

recovery  in,  132 
surgical  treatment  of,  133 
symptoms,  131 
treatment,  133 
Brady cardia,  391 
Bradytrophy,  Bouchard's,  221 
Brain  abscess,  496 
otogenous,  496 
traumatic,  496 
course  of,  498 
diagnosis  of,  498 
focal  symptoms  of,  498 
in  tuberculous  meningitis,  464 
lumbar  puncture  in,  82 
symptoms  of,  497 
treatment  of,  498 
anemia  of,  489 
appearance  of,  at  birth,  31 
circulation  of,  disturbances  of,  489 
concussion  of,  490 
growth  of,  31 
hemorrhage  of,  asphyxia  of  new-born, 

in,  126 

hyperemia  of,  489 
hypertrophy  of,  487 
in  meningococcus  meningitis,  467 


Brain,  in  serous  meningitis,  474 

inflammation  of,  in  purulent  meningitis, 
465 

malformation  of,  gross,  483 

membranes    in    meningococcus    menin- 
gitis, 467 

mental  development,  of  28 

size  of,  28 

tumor  of,  497 

water  on  the,  458 

weight  of,  28,  31 
Brandy  in  treatment  of  acute  dyspepsia, 

279 
Breast,  artificial  milking  of,  124 

cleansing  of,  42 

conical,  45 

emptying  of,  45 

in  fissured  nipple,  38 

in  mastitis,  38 

to  increase  flow  of  milk,  40 

flat,  45 

hypertrophy  of,  47 

number  of  feedings  from,  46 

nursing  by  one,  45 

Breast-fed  infants,  aerobic  organisms  in,  12 
disturbances  of  nutrition  in,  303 
idiosyncrasy  to  cow's  milk,  306 
stools  of,  11 
Breast-feeding,  305 

advantages  of,  90,  91,  92,  93,  94,  95,  96, 
98,  103,  104 

contraindications  for,  37,  306 

diarrhoea  in,  303 

disturbances  of  nutrition  in,  303 

idiosyncrasies  to,  37,  306 

favored  by  statistics,  90,  91,  92,  93,  94, 
95,96 

for  premature  children,  121,  123 

in  alimentary  intoxication,  297,  298 

in  exudative  diathesis,  305 

in  meningococcus  meningitis,  473 

in  neuropathic  individuals,  305 

in  purulent  meningitis,  466 

in  syphilis,  101,753,782 

in  tuberculosis,  37 

von  Pirquet  reaction  not  sufficient  to 
stop,  37 

prizes  for,  103 

propaganda  for,  103 

statistics  of,  90,  91,  92,  93,  94,  95,  96 

stools  in,  1 1 

technic  of,  43 

Breast-milk,  300,  302,  303,  305 
Breast-pump,  45 

Ibrahim's,  45 
Breathing,  abdominal,  3 

diaphragmatic,  3 

mixed  type,  3 

nasal,  obstruction  to,  110 

of  new-born,  3 

"puerile,"   78 

thoracic,    3 

Brennemann,  Joseph:  Diseases  of  the  diges- 
tive system,  Part  III,  p.  242 
Bromides  in  epilepsy,  549 


860 


INDEX 


Bromides,  in  tetanus,  143 
Bromidism,  in  epilepsy,  549 
Bromine  secreted  in  milk,  42 
Bronchi,  diphtheria  of,  649 
Bronchial  tubes,  foreign  bodies  in,  363 

lymph-nodes,  78,  726 
caseated,  458 
enlarged,  78 

tuberculosis  of,  721,  722,  726 
X-ray  examination  of,  737 
Bronchiectasis,  382 

diagnosis  of,  383 

pathologic  anatomy  of,  382 
Bronchiolitis,  365 
Bronchitis,  364 

asthmatic,  368 

capillary,  370 

clinical  picture  of,  371 
diagnosis  of,  372 
physical  signs  of,  371 
postmortem  findings  in,  370 
prognosis  of,  372 
treatment  of,  372 

cough  in,  365 

etiology  of,  364 

in  measles,  610 

in  scrofula,  730,  731 

membranous,  637 

mustard  pack  in,  108 

prognosis  of,  365 

prophylaxis  of,  366 

salt  steam  in,  368 

treatment  of,  367  - 
Broncho-entero-catarrh,  314 
Bronchpphony,  78 
Broncho-pneumonia,  93,  373 

aspiration  in,  374 

bacteriology  of,  373 

clinical  picture  of,  374 

death-rate  higher  in  winter,  93 

diagnosis  of,  375 

effect  of,  on  tuberculosis,  735 

following  bronchitis,  365 

physical  signs  of,  374 

prognosis  of,  375 

treatment  of,  375 
Bronchoscopy,  74 

anesthesia  in,  74 
Bronco-tetany,  373 
Bronchus,  catarrh  of,  364 

compression  of,  by  tuberculous  lymph 
nodes,  726 

rupture  of  tuberculous  node  into,  727 
Brudzinski's  neck  sign  in  meningococcus 
meningitis,  470 

in  tuberculous  meningitis,  460 
Bruit  de  diable,  159 
Bubble,  gastric,  113 
Budin's  factor,  63 

in  feeding,  63 

Buhl's  disease,  as  form  of  sepsis  of  new- 
born, 146 

Bulbar  paralysis,  progressive,  528 
Burns,  endogenous  hemolytic  poison,  166 
Burri's  methods  of  staining,  750 


Butter  in  infant  feeding,  60 
"Butter-flour"  mixture,  60 
Buttermilk,  268,  300 

for  premature  children,  124 

in  alimentary  intoxication,  298 

in  breast-fed  children,  305 

in  dyspepsia,  acute,  290 

in  intestinal  infections,  319 

overfeeding  of,  296 
Byfield,  Albert  H.:    General  prophylaxis 

and  therapy,  Chapter  V,  p.  98 

CACHECTIC  habitus,  734 

in  scrofula,  734 
Cachexia  thyreopriv.a,  227 
Caffein    in    alimentary  intoxication,   297 
in  sepsis,  148 

sodio-salicylate  in  sepsis,  148 
stimulating  action  of,  109 
Ca-ions  in  rickets,  192 
Calcification   in   pulmonary   tuberculosis, 

721 

lack  of,  in  rickets,  191,  192 
prevention  of,  193,  194 
Calcium  balance  in  spasmophilia,  533 
bromide  in  tetanus,  143 
caseinate  in  acute  dyspepsia,  290 

in  breast-fed  children,  305 
chloride  in  arthritism,  222 

in  purpura  hemorrhagica,  185 
lactate  in  acute  cory/a,  351 

in  purpura  hemorrhagica,  185 
salts  in  blood  in  rickets,  192 
in  bone  in  rickets,  192 
in  milk,  4,  5 
Calomel,  cathartic  action  of,  112 

dangers  of,  112 
Caloric  index,  20 

value  of  cow's  milk,  22 
of  cream  (10  per  cent.),  62 
of  fat,  20 
of  flour,  62 
of  human  milk,  22 
of  milk,  4 
of  protein,  20 
of  sugar,  20,  62 
of  whole  milk,  62 
Calories  dangers  of  feeding  by,  63 
for  premature  children,  123 
in  artificial  feeding,  62 
net,  21 

per  pound  body-weight,  64 
raw,  21 
Calhoun,  Henrietta  Anne:  Diseases  of  the 

heart,  Part  V,  p.  389 
Calmette  conjunctival  test  for  tuberculosis 

741 

reaction,  741 

Camphor,   digalen    in   alimentary   intoxi- 
cation, 297 

in  meningococcus  meningitis,  473 
Camphorated  oil  in  sepsis,  148 

stimulating  action  of,  109 
Cancer,  water,  246 
.Cane-sugar,  end  products  of,  17 


INDEX 


861 


Cane-sugar,  in  infant  feeding,  60,  61 
Canker  sore  mouth,  244 
Caput  obstipum,  131 

quadratum  of  rickets,  200,  201 
succedaneum,  differentiationfromcephal- 

hematoma,  129 
Caramel    produced    from    milk-sugar    by 

boiling,  7 

Carbohydrates,  action  of,  295 
and  whey,  295 
in  dyspepsia,  290,  310 
increasing  nitrogen  retention,  16 
metabolism  of,  209 

per  body-weight,  64 
Carbol-fuchsin  stain  for  fat,  273 
Carbon  dioxide,  amount  given  off,  23 

excretion  in  proportion  to  body  sur- 
face, 20 

snow  for  pigmented  moles,  851 
monoxide,  action  on  hemoglobin,  166 
Carcinoma  of  genito-urinary  tract,  456 
of  liver,  340 
of  peritoneum,  346 
Cardiac  area;  percussion  of,  7 
insufficiency,  413 
rhythm,  disturbances  of,  389 
Care  of  the  child,  66 

of  the  normal  infant,  Chapter  II,  p.  36 
Carlsbad  salts,  artificial,  112 
Carpopedal  spasms  in  tuberculous  menin- 
gitis, 464 

tetanic,  in  spasmophilia,  536 
Carriers,  in  diphtheria,  638 

in  meningococcus  meningitis,  467 
in  typhoid  fever,  688 
Case  history,  taking  of,  70. 
Caseated  bronchial  nodes,  458 

tuberculous  nodes,  458 
Casein  calcium  preparations,  286,  290 
in  therapeutics,  275 
indigestibility  of,  257 
in  cow 's  milk,  58 
Caseinogen,  4,  7 
Castor  oil,  advantages  of,  112 

combined    with    aromatic    syrup    of 

rhubarb,  112 
disguising  taste  of,  112 
in  acute  dyspepsia,  290,  308 
Castration,  effects  of,  236 
Casts  in  alimentary  intoxication,  292 
Cataleptic  condition  in  alimentary  intox- 
ication, 292 
Catatonia,  570 

Catarrh,  aggravated  by  cooling  of  body- 
surface,  101 

by  feeding  of  fats  and  proteins,  101 
of  colon  in  mucous  colitis,  310 
of  mucous  membranes  in  scrofula,  730 
Catarrhal  diathesis,  213 
gastro-enteritis,   314, 
jaundice,  339 

treatment  of,  339 

troubles,  constitutional  resistance  to,  101 
susceptibility  transmitted  by  parents, 
101 


"Catching  cold,"  101 
Cathartics,  112 
Catherization  of  bladder,  80 
of  duodenum,  322 
of  ureters,  80 

Cauda  equina  at  birth,  31 
Cavernous  sinus,  thrombosis  of,  457 
Cella  turcica  in  hypopituitarism,  236 
Cellulose,  a  polysaccharide,  17 
Central  nervous  system,  sclerosis  of,  510 
Centres  of  ossification,  29 
Cephalhematoma,  external,  127,  188 
bilateral,  127 
bleeding  time  in,  128 
coagulation  time  in,  128 
diagnosis  of,  128 
differentiation  from  meningocele,  128 

from  caput  succedaneum,  129 
etiology  of,  127 

hemorrhagic  disease  of  new-born,  128 
opening  of,  129 
prognosis  of,  129 
resorbtion  of,  127 
surgical  interference  in,  129 
symptoms  of,  127 
treatment  of,  129 
internal,  129 

cerebral  pressure  from,  129 
fracture  causing,  129 
prognosis  in,  129 
Cephalocele,  484,  485,  491 
Cereal  water,  65 
Cerebellar  chorea,  506 
Cerebellum  at  birth,  31 
Cerebral  ataxia,  acute,  494 
diplegias,  familial,  524 
hemorrhage  of  new-born,  126,  129 
asphyxia  from,  129,  130 
aspiration  of,  130 
autopsies  in,  130 
blood,    injections    of  whole,    in, 

130 

cerebrospinal  fluid  in,  130 
convulsions  from,  129 
diagnosis  of,  130 
epilepsy  from,  130 
etiology  of,  129 

hemorrhagic     disease     of     new- 
born causing,  129 
idiocy  from,  130 
instrumental   deliveries   causing, 

129 

Little's  disease  and,  130 
lumbar     puncture     in    differen- 
tiating,   130 

paralyses  from,  129,  130 
prognosis  of,  130 
puncture  in,  130 
symptoms  of,  129 
trauma  causing,  129 
irritation  in  alimentary  intoxication,  292 
palsy,  infantile,  499 

atonic-astatic  type  of,  506 
paralysis,  499 
etiology  of,  499 


862 


INDEX 


Cerebral  paralysis,  infective,  499 
pathologic  anatomy  of,  499 
symptoms  of,  499 
traumatic,  499 
unilateral,  501 
pressure  from  internal  cephalhematoma, 

129 

tremor,  acute,  493 
tumor,  497 
course  of,  498 
diagnosis  of,  498 
focal  symptoms  of,  498 
symptoms  of,  497 
treatment  of,  498 
Cerebro-cerebellar  diplegia,  506 
Cerebrqspinal  disease,  familial,  524 

fluid  in  cerebral  hemorrhage  of  new-born, 

130 

in  hydrpcephalus,  480 
meningitis,  471 
Certified  milk,  55,  60 
Cervical  node,  caseated,  458 
Chafing,  care  of,  67 
Change  of  air,  psychic  effects  of,  118 
Charcoal,  animal,  mechanical  influence  of, 

on  bowels,  114 

Cheek,  tuberculosis  of,  primary,  721 
Chemical  findings  in  rickets,  192 
Chest,  circumference  of,  72 
examination  of,  75 
short  rounded,  in  rickets,  192 
Cheyne-Stqkes   breathing  in   tuberculous 

meningitis,  462 

Chicken  breast  in  rickets,  199 
Chicken-pox  (see  varicella),  623 
allergy  in,  722 

combined  with  diphtheria,  576 
with  measles,  576 
with  scarlet  fever,  576 
hemorrhages  in,  185 
Chickens,  polyneuritis  of,  19 
Child,  antenatal  protection  of,  98 
care  of,  66 
carrying  of,  68 
delinquent,  106 
handling  of,  68 
illegitimite,  unfavorable  position  of,  in 

infant  mortality,  88,  89,  93,  94 
menu  of,  51,  65 
obedience  in,  69 

pen  in  preventing  dirt  diseases,  100 
psychic  development  of,  32 
sick,  general  symptomatology  of,  70 

technic  of  examination  of,  70 
stupid  quarter  of,  32 
training  of,  69,  100 
water  contents  of,  1 
welfare  movement,  102 
Childhood,    arterio-sclerosis    almost    un- 
known in,  2 
diseases  of,  571 
every  period  its  peculiar  disease  groups, 

94 

Chills  absent  in  sepsis  of  new-born,  146 
Chlamydozoa  blennorrhcea,  150 


Chloracetic  acid  for  umbilical  granuloma. 

139 

Chloral  hydrate,  administration  of,  119 
in    alimentary    intoxication,    danger 

of  using,  297 

in  disturbances  of  nutrition  in  breast- 
fed children,  304 
in  eclamptic  convulsions,  116 
in  insomnia,  116 
in  purulent  meningitis,  467 
in  serous  meningitis,  476 
in  tetanus,  143 

in  tuberculous  meningitis,  465 
Chlorine  in  milk,  4,  5 
Chloroform  dangerous  for  children,  119 

anesthesia,  effect  on  lactation,  42 
Chloro-lympho-myelosarcomata,  181 
Chloroma,  176,  181,  205 
Chloro-myelosarcomata,  181 
Chlorophyll,  compared  with  hemoglobin, 

162 
Chlorosis,  163 

Blaud 'spills  in,  173 
blood  percentage  in,  163 
diagnosis  of,  163 
etiology  of,  163 
mesentery  thrombosis  in,  164 
nature  of,  163 
plethora  in,  163 

pseudo-anemia  mistaken  for,  164 
pubertal,  163,  164 
symptoms  of,  163 
treatment  of,  174 
Chocolate  for  children,  117 

for  disguising  taste  of  medicines,  119 
Choked  disc  in  serous  meningitis,  475 

in  tuberculous  meningitis,  462 
Cholemia,  endogenous  hemoly  tic  poison,  166 
Cholera  infantum,  255,  291 

nostras,  resemblance  to  alimentary  in- 
toxication, 294 
resemblance  to  alimentary  intoxication, 

294 
Choleric  alimentary  intoxication  in  chronic 

dyspepsia,  311 
Chorea,  cerebellar,  506 
chronic  progressive,  528 
electrica,  552,  553 
general,  506 
hemi-,  551 
Huntington 's,  528 
hysterical,  552 
minor,  549 
age  in,  551 

clinical  picture  of,  550 
course  of,  551 
diadococinesis  in,  552 
diagnosis  of,  552 
;     duration  of,  551 

endocarditis,  acute,  in  400 
etiology  of,  551 
heart  in,  551 
patellar  reflex  in,  551 
pathogenesis  of,  552 
rheumatism  in,  551 


INDEX 


863 


Chorea,  minor,  sex  in,  551 

termination  of,  551 
mollis,  551 
nocturna,  550 
paralytic,  551 
Choreic  paresis,  503 

Choreiform  type  of  alimentary  intoxica- 
tion, 294 
Choroid  plexus  in  serous  meningitis,  474 

tubercles  464,  729 
Choroiditis,  syphilitic,  771 
Chrondrodystrophia,  236 
Chrondromalacia,  236 
Chvostek's  phenomenon,  464 

in  spasmophilia,  531 
Cinchona,  aromatic  tincture  of,  117 
Circulation  stimulants,  109 
caffein,  109 
camphorated  oil,  109 
digalen,  110 
digipuratum,  110 
digitalis,  109 
digitoxin,  soluble,  110 
epinephrin,  109 
saline  solutions  in,  109 
strophanthus,  109 
Circumcision  and  erysipelas,  713 
Cirrhosis  of  liver,  339 
biliary,  340 
icteric,  340 
syphilitic,  339 
Cities  with  highest  and  lowest  death-rate 

in  the  United  States,  91 
Claw-hands,  526 
Cleanliness  in  care  of  children,  66 

in  milk  supply,  55 
Cleft  palate  preventing  nursing,  39 
Clonic  convulsions,  34 

in  meningococcus  meningitis,  469 
Clothes  basket  for  premature  children,  122 
Clothing,  excessive,  and  heat  injury,  261 

of  premature  infant,  122 
Cloudy  swelling  of  kidneys,  428 
Coagulation  time,  in  cerebral  hemorrhage, 

130 

in  general  hemorrhagic  disease  of  new- 
born, 128 

in  melena,  prolonged,  149 
in  umbilical  hemorrhage,  144 
Cocain,  use  of,  to  be  avoided  in  children, 

119 

Cocoa  for  children,  117 
Cod-liver  oil,  in  rickets,  206,  207 
in  tuberculosis,  747,  749 
value  of,  117 

Codein  sulphate,  dose  of,  115 
narcotic  action  of,   115 
value  of,  1 15 
"Coffee    grounds"    vomit   in    alimentary 

intoxication,  293 
Cohen's  bacillus  in  purulent  meningitis, 

465 
Cold,  catching,  101 

packs  in  alimentary  intoxication,  297 
sores,  826 


Cold,  sponging,  107 

Cold  water  treatment  for  preventing  colds, 

101 

Colic,  treatment  of,  115 
Collapse  in  alimentary  intoxication,  292 

threatened,  alcohol  in,  108,  109 
Collargol  useless  in  sepsis,  148 
Colics' law,  753 
Colloidal  bismuth  oxide,  astringent  action 

of,  114 

Colon,  absorption  by,  10 
catarrth,  chronic,  308 
dilatation  of,  330 
hypertrophy  of,  330 
pyelqcystitis,  217 
washing  of,  in  alimentary  intoxication, 

297 

Colostral  corpuscles,  6 
Colostrum,  6 

amount  secreted,  45 
nitrogen  contents  of,  16 
re-lactation  and,  51 
resemblance  to  "witch's  milk,"  151 
Coma,  dyspeptic,  307 

in  alimentary  intoxication,  292 
in  tuberculous  meningitis,  463 
Combined  infectious  diseases,  576,  577 
Comedo,  840 

Comedones,  grouped,  840 
Commotio  cerebri,  490 
Compresses,  moist,  in  fever,  107 
Conception  prevented  by  nursing,  43 

prevention  of,  sign  of  degeneracy,  87 
Condensed  milk  in  infant  feeding,  62 
Condylomata,  774 

Congenital  debility  increasin  g  death-rate ,  95 
malformations  increasing  death-rate,  95 
spastic  pyloric  stenosis,  322 
strid9r,  360 
syphilis,  754 

meningitis  in,  476 

no  reason  why  child  should  not  nurse, 

39 

Conjunctival  instillation  of  tuberculin,  738 
Conjunctivitis,    catarrhal,    from     Crede's 

method,  150 
lymphatic,  731 
phlyctenular,  731 
pneumococcic,  150 
tuberculous,  727 

Considerations,  general,  Chapter  I,  p.  1 
Constipation,  331 
diagnosis  of,  331 
of  artificially-fed  children,  332 
of  breast-fed  infants,  331 
of  older  children,  332 
treated  by  calomel,  112 
by  castor  oil,  112 
by  enemata,  111,  112 
by  milk  of  magnesia,  112 
by  phenolphthalein,  112 
by  rhubarb,  112 
by  saline  laxatives,  112 
by  suppositories,  112 
Constitution,  neuropathic,  553 


864 


INDEX 


Constitution,  psychopathic,  553 
Constitutional  anomalies,  Part  II,  p.  156, 
213,  261 

causes  of  diseases,  305 
Contact  infections,  96,  573 
Contagious  diseases,  spreading  of,  99,  100 

index  in  contagious  diseases,  574 
Contamination  of  milk,  55 
Convalescence  from  infectious  diseases, 

577 
Convulsions,  clpnic,  34 

differential  diagnosis  of,  542 

disturbances  of  metabolism  causing,  34 

eclamptic,  chloral  hydrate  in,  116 

emotional  respiratory,  557 

functional  epileptic,  541 

idiopathic,  541 

in  alimentary  intoxication,  292 

in  cerebral  hemorrhage,  129,  130 

in  meningococcus  meningitis,  468,  469, 
470 

in  purulent  meningitis,  466 

in  serous  meningitis,  474,  475 

in  tuberculous  meningitis,  463 

lumbar  puncture,  in,  542 

nervous,  541 

paralysis  following,  542 

psychasthenic,  541 

terminal,  541 

tonic,  34 

treatment  of,  543 

unilateral,  543 
Convulsive  diseases,  530 

rage,  557 
Cooling  box  of  Fliigge,  57 

packs,  107 
Cord  of  infant,  31 
Corn  flour  in  infant  feeding,  61 
Cornea,   involvement  of,   in  ophthalmia, 
150,  151 

pannus  of,  in  scrofula,  732 

ulcers  in  scrofula,  732 
Corneal  reflex,  33 
Corpuscles,  collostral,  6 
Corrosive  esophagitis,  254,  255 
Coryza,  347,  348,  349,  350 

acute,  350 

treatment  of,  351 

chronic,  352 

horse  dandruff  causing,  350 

in  scrofula,  733 

in  syphilis,  39,  757 

pathologic  anatomy  of,  350 

treatment  of,  by  epinephrin,  39 

tuberculin,  349 
Cough,  spasmodic,  opium  for,  114 

troublesome,  narcotics  in,  115 

whooping,  672 

Counterirritants,  care  in  use  of,  120 
Cow,  diet  of,  56 

mastitis  of,  56 
Cow-pox,  630 

Cow's  milk,  caloric  value  of,  22 
casein  in,  58 
causing  tuberculosis,  721 


Cow's  milk,  cleanliness  of,  55 
composition  of,  4 
deficient  in  iron  salts,  1 
inadequacy  of,  256 
iron,  amount  of,  in,  161 
limit  of  amount  of,  65 
milk-sugar  contents  of,  5 
peculiarities  of,  4 
per  pound  of  body-weight,  64 
Coxa  vara  in  rickets,  200 
"Cracked   pot   resonance"   in   screaming 

children,  78 
Cradle,  use  of,  67 
Cradle-cap,   221 
Cramps,  535 

leg  muscles  in  alimentary  intoxication, 
293 
Cranial  nerves  at  birth,  32 

congenital  functional  defects  of,  488 
paralysis  of,   in  tuberculous   menin- 
gitis, 462 
puncture,  84 

in   internal   hemorrhagic    pachymen- 

ingitis,  457,  458 
vessels,  embolism  of,  490 

thrombosis  of,  490 
Craniotabes  in  rickets,  198,  201,  204 

palpating  for,  72 
Cream  in  infant  feeding,  59 
10  per  cent.,  calories  of,  62 

how  obtained  from  milk,  59 
Crede's  prophylactic  method,  150 

universal  use  of,  99 
Creosote  in  tuberculosis,  747,  749 
Cretinism,  227 

endemic  (see  also  hypothyreosis,  226), 

231 

deafness  in,  229,  234 
drinking  water  as  cause  of,  231 
geographic  distribution  of,  231 
hypogenitalism  in,  232 
hypopituitarism  in,  232 
thyroid  gland  in,  232 
Crisis  in  lobar  pneumonia,  379 
Crossed  hemiplegia  in  tuberculous  menin- 
gitis, 463 

pyramidal  tracts  in  infancy,  31 
Croup,  diphtheritic,  651 
membranous,  637 
true,  361 

Crow,  inspiratory,  360 
Crusta  lactea,  798 
Curdling  of  milk,  time  of,  56 
Cure  in  syphilis,  785 
Cutical  navel,  134 
Cuticular  angiospasm,  175 
Cutis  laxa,  228 
Cutting  of  teeth,  29 
Cyanosis  in  congenital  heart  lesions,  394 
Cystitis,  acute  primary,  441 
due  to  gaping  of  vulva,  13 
Cystopyelitis,  439,  716 
Cystoscopic  examination  of  the  bladder,  80 
Cysts  of  peritoneum,  346 
Czerny  's  anemia,  170,  171 


INDEX 


865 


DAIRY  cattle,  diet  of,  56 

Dark  field  illumination,  751 

Darwinian  theory  as  to  high  mortality  of 

children,  89 
Day  nurseries,  104 
Deafness,  in  hypothyreoses,  229,  234 

in  purulent  meningitis,  466 

in  rickets,  240 

in  syphilis,  777 
Death,  postdiphtheritic  cardiac,  553 

sudden,  in  status  thymico-lymphaticus. 
217 

thymic,  217 

Death-rate  increased  by  birth  injuries,  95 
by  congenital  debility,  95 

in  first  year  per  1000  born  alive,  86 

malformations  and,  95 

per  1000  inhabitants,  86 

relation  to  birth-rate,  86 
Deaths  from  tuberculosis,  723 
Debility,  congenital,  increasing  death-rate, 
95 

mental,  567 

Decalcification  in  rickets,  191 
Decomposition,  265,  278,  302 

breast-feeding,  in,  282 

course  of,  281 

definition  of,  278 

diagnosis  of,  282 

duodenal  ulcer  in,  281,  289 

hunger  period  in,  287 

intoxication  and,  291 

metabolism  in,  279 

of  milk,  55 

pathogen esis  of,  279 

prognosis  of,  282 

protein  milk  in,  285,  286,  287,  288 

Quest's  quotient  in,  282 

reversion  in,  279 

starvation  in,  282 

stools  in,  278 

symptoms  of,  278 

treatment  of,  282 

urine  in,  278 
Deficiency  diseases,  19 
Degeneracy,    prevention    of    conception, 

sign  of,  87 

Degeneration,  stigmata  of,  567 
Degenerative  neoplasmata,  848 
Dehydration  in  alimentary  in  to  xication,296 
Delinquent  child,  106 
Dementia  praecox,  570 
Dentition,  29 

delayed,  in  rickets,  198 

first,  30 

normal  course  of,  30 

second,  30 

Dermatitis,  exfoliativa,  811,  813 
epidemic,  character  of,  813 
therapy  of,  814 

venenata,  830 
definition  of,  830 
diagnosis  of,  831 
symptoms,  of,  830 
treatment  of,  831 
55 


Dermatographia  in  meningococcus  men- 
ingitis, 470 

in  tuberculous  meningitis,  460,  464 
Dermatoses,  dry  scaly  inflammatory,  831 

exudative,  825 
Dermoid  of  peritoneum,  346 
D'Espine's  sign,  78 
Detoxicated  salt  solution  in,  297 
Detoxication,  alimentary,  295,  296 
Development,  retardation  of,  483 
Dextrin  in  acute  dyspepsia,  290 
Dextri-maltose,  63 
Dextrose,  17 
Dhobie  itch,  836 
Diabetes  insipidus,  445 
diagnosis  of,  446 
duration  of,  446 
treatment  of,  446 
mellitus,  208 
acetoacetic  acid  in,  208 
acetone  odor  in,  208 
acidosis  in,  208,  209 
alcohol,  use  of,  in,  209 
ammonia  coefficient  in,  208 
casts  in,  208 
disaccharides  in,  209 
edibles  poor  in  carbohvdrates,  use  of, 

in,  209 

fatal  ending  of,  208 
hediosit,  use  of,  in  209 
hereditary  endogenous    degeneration, 

208 

intermarriage  and,  208 
inulin,  use  of,  in,  209 
lymphatic  organs  in,  211 
monosaccharides  in,  209 
oatmeal  diet  in,  209 
oxybutyric  acid  in,  208 
pancreatic  origin  of,  208 
potatoes,  mashed,  in,  209 
proteinuria  in,  208 
regimen  for,  211 
sodium  bicarbonate  in  acidosis,  209 

citrate  in  acidosis,  209 
syphilis  and,  208 

thyroid  gland,  dangers  of,  in  treat- 
ment of,  211 
treatment  of,  211 
urine  in,  208 

Diacetylic  tannic  acid,  114 
Diadococinesis  in  chorea,  552 
Diaphragmatic  hernia,  327 

asphyxia  of  new-born  from,  126 
Diarrhoea,  deaths  from,  92 
in  breast-fed  children,  303 
in  premature  children,  124 
increased  during  summer  months,  92 
Diastase  of  saliva,  18 
Diatheses,  213 
catarrhal,  213 
combined,  214 

effect  of,  on  contagious  diseases,  577 
exudative,  214,  305,  788 
hemorrhagic,  168,  184 
habitus  of,  215 


866 


INDEX 


Diatheses,  inflammatory,  214,  788 
lymphatic,  213,  788 
neuropathic,  213 
rickitic,  196 
spasmophilic,  530 
stigmata  in,  213 
Diazo-reaction  of  urine  in  granulomatosis, 

182 

in  measles,  606 
in  tuberculous  meningitis,  464 
in  typhoid  fever,  695 
Diet  for  nursing  mother,  41 
Diethyl-barbituric-acid,    soporific    action 

of,  116 
Dietrich,  Henry:    Tuberculosis,  Part  IX, 

p.  720 

Digalen,  stimulating  action  of,  110 
Digestibility  of  milk,  4 
Digestive  tract,  flora  of,  11,  12 

system,  diseases  of,  Part  III,  p.  242 
Digipuratum,  stimulating  action  of,  110 
Digitalis,  cumulative  action  of ,  109,  119 
soluble,  stimulating  action  of,  110 
stimulating  action  of,  109 
Dilution  of  milk,  58 

Dimethyl-amido  antipyrin  in  fever,  107 
Dimethylamino-antipyrin,  473 
Diphtheria,  637 

anaphylaxis  in,  665,  666 
animal  diagnosis  of,  659 
antidiphtheritic  serum  in,  644 
antitoxin  in,  644 

anaphylaxis  from,  665,  666 
dose  of,  661 

immunity  unit  (I.  TJ.)  of,  661 
intravenous  injection  of,  661 
method  of  preparing,  661 
mortality  after  use  of,  663 
muscular  injection  of,  661 
prophylactic  dose  of,  661 

serum  disease  from,  664 
reinjection  causing,  664 
subcutaneous  injection  of,  661 
aural,  648 
blood  in,  654 

bacteriological  diagnosis  of,  658 
cardiac  death  in,  653 
carriers,  638 
clincial  course  of,  642 
combined  with  chicken-pox,  577 
with  measles,  577,  612 
with  scarlet  fever,  577 
complications  of,  653 
contact  transmission  in,  639 
convalescence  in,  646 
cricotracheotomy,  avoidance  of,  671 
croup  in,  651 

kettle  in,  667 
death-rate  from,  94 
definition  of,  637 
diagnosis  of,  656 

bacteriologic,  658 
diet  in,  668 
differential  diagnosis  of,  656 

from  Bednar's  aphthae,  657 


Diphtheria,  differential  diagnosis  of,  from 

lacunar  angina,  656 

from  laryngitis,  acute,  of  measles, 
657 

from  luetic  angina,  657 

from  pseudocroup,  657 

from  scarlatinal  angina,  656 

from  thrush,  657 

from  Vincent's  angina,  656,  657 
digestive  apparatus  in,  654 
disease-picture  of,  642 
dose  of  antitoxin  in,  648,  661 
prophylactic,  661 

anaphylaxis  from,  666 
droplet  infection  in,  639 
epidemic,  640 
epinephrin  in  668 
epistaxis,  in,  355 
erythema  of  skin  in,  655,  665 
exanthemata  in,  665 
fetor  ex  ore  in,  642 
hemorrhage  in,  645 
hemorrhagic  rhinitis  in,  457 
immunization  in,  640 
immunity  in,  639 
incubation  period,  642 
intubation  in  laryngeal,  650,  668,  669 

method  of  performing,  669,  670 
itching  after  use  of  antitoxin,  665 
laryngeal  croup  in,  644,  667 
localization  of,  rare,  651 
Loeffler's  bacillus,  causative  agent,  of, 

637,  638 

lymph  nodes  in,  653 
malignant,  646 
measles  and,  640 
membrane,  location  of,  in  642,  643,  644, 

645,  646 

peculiarities  of,  652 
mild  forms  of,  644 
mortality  from,  in  Bavaria,  572 

in  Prussia,  571 
mouth,  hygiene  of,  in,  667 
nasal,  348,  639,  646,  647 
of  bronchi,  648 
of  conjunctiva,  651 

primary,  651 
of  ear,  648 
of  eyes,  667 
of  heart,  389,  641 
of  kidneys,  654 
of  larynx,  648,  657 
primary,  649 

air  hunger  in,  650 

antitoxin  in,  650,  651 

arytenoid  cartilages  in,  649 

broncho-pneumonia  in,  651 

epiglottis  in,  649 

hoarseness  in,  649 

intubation  in,  650,  651 

tracheotomy  in,  650,  651 

vocal  cords  in,  650 
of  mouth,  651 
of  nervous  system,  654 
of  nose  348,  639,  646,  647,  667 


INDEX 


867 


Diphtheria,  of  pharynx,  651 

of  respiratory  apparatus,  653 

of  skin,  652,  655 

of  trachea,  648,  649 

of  umbilicus,  139 

of  vascular  system,  653 

of  vulva,  652 

otitis  media  in,  648 

paralyses  in,  654,  655,  658 
postdiphtheritic,  658 

paresis  in,  654,  655 

pathological  anatomy  of,  641 

pathogenesis  of,  641 

precipitins  in,  665 

prognosis  of,  659 

during  measles,  660 

prophylaxis  of,  660 

pulse  in,  643,  645 

rare  localizations  of,  851 

recurrences  in,  639 

Schick  reaction  in,  639,  666 
according  to  age  in,  640 

septic,  646 

sequelae  of,  653 

serum  disease  and,  664,  665 

severe  forms  of,  645 

sporadic,  640,  641 

steam  in,  667 

streptococci  in,  646 

susceptibility  to,  639 

thrombopenia  in,  185 

tonsils  in,  642 

toxin  antitoxin  reactions  in,  640 

tracheotomy  in  laryngeal,  650,  668,  669 

treatment  of,  660,  668, 

urine  in,  643 

vaccine,  666 

virulent  to  guinea  pig,  638 

whooping-cough  and,  672 
Diphtheritic  stomatitis,  243 
Diphtheroid  angina,  251 
Diplegias,  cerebro-cerebellar,  506 

familial  cerebral,  524 

spastic  infantile,  499,  503 
Diplococci,   Gram-negative,   in    meningo- 

coccus  meningitis,  468 
Diplococcus  intracellularis,  467,  473 
Dirt  infections,  96,  100 

child-pen,  a  preventive  for,  100 
Disaccharides,  17,  209 
Diseases,  acute  infectious,  Part  VIII,  p.  571 

deficiency,  19 

due  to  constitutional  causes,  305 

endogenous,  303,  305 

exogenous,  303 

not  to  be  treated,  but  the  patient,  106 

of  metabolism,  Part  II,  p.  156 

of  the  genito-urinary  system,  Part  VI, 
p.  419 

of  the  heart,  Part  V,  p.  389 

of  the  nervous  system,  Part  IX,  p.  457 

of  the  new-born,  Part  I,  p.  121 

of  the  respiratory  organs,  Part  IV,  p.  347 

of  the  skin.  Part  XI,  p.  787 

predisposition  to,  213 


Disposition  to  contagious  diseases,  574 
Disturbance  of  balance,  264 
of  nutrition,  255,  256 

of  breast-fed  infants,  303 
Diverticulum,  Meckel's,  135 
Dosage,  rule  for,  in  childhood,  119 

by  weight  of  child,  119 
Drawing  pains  of  back,  relief  of,  42 
Drinking   water,    cause   of   endemic   cre- 
tinism, 231 

Driving  in  of  eczema,  802 
Drop  heart  in  masturbation,  418 
Droplet  infection  in  contagious  diseases. 

572,573 

in  grippal  diseases,  700 
in  influenza,  700 
in  pertussis,  672 

Drumstick  fingers  in  tuberculosis,  726 
Ductus  arteriosus,  patent,  397 

venosus  arantii,  133 
Dukes '  fourth  disease,  594,  622 

incubation  period  of,  622,  623 
prodromes  of,  622 
•Duodenal  catheterization,  322 

ulcer  in  decomposition,  281 
Dura  mater,  hygroma  of  the,  457 
Duration  of  infection  in  contagious  dis- 
eases, 579 

Dusting  powders,  66 
Dwarfism  in  rickets,  203 

true,  nose  in,  347 
Dwyer's  mouth  gag,  74 
Dysbasia,  progressive  lordotic,  525 
Dysentery,  316 
bacilli  in  infectious  intestinal  catarrh, 

314 

diagnosis  of,  318 
etiology  of,  316 
inanition  in,  318 
treatment  of,  318 
Dysentery-like  enteritis  in  intestinal  tract, 

315 
Dyspepsia,  acute,  307 

acetone  in  urine  in,  307 

odor  in,  307 
albumin  in,  307 
alimentary  fever  in,  292,  307 
antimony,  wine  of,  in,  308 
appetite,  loss  of,  in,  307 
asthmatic,  308 
buttermilk  in,  290 
calcium  caseinate  in,  290 
calomel  in,  308 
carbohydrates  in,  290 
castor  oil,  in,  290,  308 
casts  in,  307 
catharsis  in,  308 
cerebral  irritation  in,  307 
coma  in,  307 
convulsions  in,  307 
constipation  in,  307 
coryza,  parenteral,  and,  29-1 
dextrin  in,  290 
dextrinized  flour  in.  290 
diagnosis  of,  289 


868 


INDEX 


Dyspepsia,  acute,  diarrhoea  in,  289,  307 
dyspnoea  in,  308 
dystrophy  and,  289 
emetics  in,  308 
enemata,  glycerin,  in  308 

high,  in,  290 
enteroclysis  in,  308 
etiology  of,  289 
fats  in,  290 
fetor  in,  307 
fever  in,  307 
flour  soups  in,  290 
from  overfeeding,  304 
from  underfeeding,  304 
gastric  lavage  in,  290,  308 
glycerin  enemata  in,  308 
grippe,  parenteral,  and,  291 
gruel  in,  290 
headache  in,  307 

idiosyncrasy  to  breast-milk  in,  306 
in  chronic  dyspepsia,  289 
influenza  and,  308 
intoxication  in,  291 
ipecac  in,  308 
lavage,  gastric,  in,  308 
liquid  diet  in,  308 
malaise  in,  307 
maltose  in,  290 
meat  broth  in,  290 
meteorism  in,  308 
nausea  in,  307 
of  the  overfed,  304 
of  the  underfed,  304 
parenteral  infection  in  acute,  291 
prognosis  of,  289 
prostration  in,  307 
protein-milk  in,  290 
pulse  in,  307 
resemblance  to  meningitis,  308 

to  paratyphoid,  308 

to  typhoid,  308 
respirations  in,  307 
rhubarb  in,  308 
saccharin  in,  290,  304 
spinal  irritation  in,  307 
starvation  treatment  of,  290 
sudden  onset  in,  307 
sugar  in  urine  in,  307 
symptoms  of,  289 
tongue  in,  307 
treatment  of,,  290 
urine  in,  307 
vomiting  in,  307 
weight  in,  290,  291 
wine  of  antimony  in,  308 
chronic,  308 

acute  dyspepsia,  cause  of,  308 
anemia  in,  309 
anorexia  in,  309 
appetite  in,  309 
coma,  307 
constipation  in,  309 
dilatation  of  stomach  in,  309 
dyspepsia,  acute,  cause  of,  308 
dystrophy  in,  289 


Dyspepsia,  chronic,  enteral,  cause  of,  308 
eructation  in,  309 
etiology  of,  308 
gastric  origin  of,  309 
gastro-paresis  in,  309 
hypotonicity  in,  309 
overfeeding,  258 
parenteral  cause  of,  308 
rickets  in,  309 
spasmophilia  in,  309 
starvation  in,  318 
stomach-tube,  use  of,  in,  309 
stools  in,  309 
test-meal  in,  309 
vomiting  in,  309 
Dyspeptic  coma,  307 
Dysthyreosis,  226 

Dystrophia,  of  the  genitalia,  235,  236 
Dystrophy,  264,  265,  302 
from  flour  feeding,  269 
metabolism  of,  271 
pathogenesis  of,  271 
prognosis  of,  271 
prophylaxis  of,  271 
stools  in,  270 
symptoms  of,  269 
treatment  of,  271 
from  inanition,  272 
diagnosis  of,  272 
treatment  of,  272 
intoxication  and,  291 
progressive  muscular,  527 
with  diarrhoea,  264,  273 
diagnosis  of,  276 
dietetic  treatment  in,  276 
etiology  of,  273 
pathogenesis  of,  274 
prognosis  of,  276 
symptoms  of,  273 
variation  in  course  of,  275 
with  dyspepsia,  289 
without  diarrhoea,  264,  265 
etiology  of,  266 
metabolism  of,  267 
pathogenesis   of,   266 
prognosis  of,  267 
symptoms  of,  265 
treatment  of,  267 
Dysuria,  angiospastic,  426 

EAR  complications  in  meningococcus  men- 
ingitis, 468,  471 

foreign  bodies  in,  360 

middle,  diseases  of,  355,  465 

scrofula  of  731,  733 
Ear-drum  in  otitis  media,  357,  358 

examination  of,  356 

rupture  of,  358 
Eburnation  in  rickets,  192 
Echinocpccus  cyst  of  liver,  340 

of  peritoneum,  346 
Eclampsia,  530 

non-spasmophilic,  541 
Eclamptic  convulsions  (synonyms: fits, 

spasms,  cramps),  535 


INDEX 


869 


Economic  assistance  to  mothers,  104 
Economo's  disease,  494 
Ecthyma,  811 

treatment  of,  812 
Ectogenous  obesity,  210 

poisons,  157 

Ectropion  in  scrofula,  733 
Eczema,  788,  790,  791 

acute,  792 

chronic,  792 

classification  of,  792 

constitutional,   796 

crustosum,  792 

death  from,  802 

definition  of,  791 

driving  in  of,  802 

dry,  disseminated,  796,  797 

endogenous,  789,  791 

erythematosum,  792 

external  causes  of,  790,  791 

infantile,  788,  790 

injury,  external,  causing,  791 

internal  causes  of,  789,  791 

intertriginous,   793 
feeding  in,  793,  794 
location  of,  793 
treatment  of,  793 

madidans,  792 

marginatum,  836 

mask,  891 

metabolism  in,  797 

of  head,  796 

papulosum,    792 

predisposition  to,  788,  791 

pustulosum,  792 

rubrum,  216,  217 

scratching  in,  790,  799 

scrofulous,  730,  823 

squamosum,    792 

status  lymphaticus  and,  803 

tar  in,  800,  802 

treatment  of,  799 
dietetic,  799 
local,  799 

vesiculosum,  792 

weeping,  crusted,  796 

zinc  oxide  in,  800 
Edema  neonatorum,  153 
of  new-born,  153 

nephritis  in,  absence  of,  153 
salt,  abuse  of,  in  153 
Eggs,  causing  urticaria,  804 
Eiweiss  Milch,  285 
Elastic  bands  for  tying-off  umbilical  cord, 

144 

Electric  heating  pads,  108 
dangers  from,  108 

reactions  in  meningococcus  meningitis, 
472 

tests,  82 

Electrocardiograms,  389 
Electrocardiograph,  389 
Electrode,  Stintzing's,  82 
Emaciation  in  children,  211 

ki  tuberculous  meningitis,  462 


Emboli,  arterial,  417 
Embolism  of  cranial  vessels,  490 

with  gangrene  in  paroxysmal  hemoglobi- 

nuria,  166 

Emetics  in  acute  dyspepsia,  308 
Emotional  respiratory  convulsions,  557 
Emphysema,  382 
Empyema,  384 
course  of,  385 

in  meningococcus  meningitis,  471 
prognosis  of,  383,  386 
treatment  of,  383 
tuberculous,  386 
Encephalitis,  acute,  491 

asphyxia  of  new-born  from,  126 
course  of,  492 
diagnosis  of,  493 
etiology  of,  491 
flea-bite,  492 

pathologic  anatomy  of,  492 
prognosis  of,  493 
symptoms  of,  492 
treatment  of,  493 
epidemic,  494 
lethargic,  494 
purulent,  496 

End  products  of  nitrogen  metabolism,  16 
Endarteritis,  syphilitic,  771 
Endocarditis,  acute,  400 
chorea  causing,  400 
course  of,  402 
diagnosis  of,  402 
etiology  of,  400 

in  meningococcus  meningitis,  471 
in  sepsis  of  new-born,  146 
occurrence  of,  400 
prognosis  of,  403 
rheumatism  causing,  400 
symptoms  of,  401 
treatment  of,  403 
chronic,  403 

valvular  lesions  from,  403 
congenital,  401 
ulcerative,  402 
Endochondral  ossification,  disturbance  of, 

in  rickets,  191 

Endocrine  organs,  deficiency  of,  in  exuda- 
tive diathesis,  219 
Endogenous  diseases,  303 
of  muscular  system,  522 
of  nervous  system,  522 
obesity,  210 
poisons,  157 

Enemata,  administration  of,  111 
cold  water,  in  hyperpyrexia,  107 
glycerin,  112 

in  tuberculous  meningitis,  465 
oil,  111 

salt-solution,  111 
soap,  112 

Energy  quotient,  21 
Enteric  fever  (typhoid  fever) ,  688 
Enteritis,  asphyxia  of  new-born  from,  126 

deaths  from,  92 
increased  during  summer  months,  92 


870 


INDEX 


Entero-catarrh,  291 
Enteroclysis,  110 

apparatus  for,  111 

glucose  in,  111 

in  acute  dyspepsia,  308 

in  tetanus,  143 

Ringer's  solution  in,  111 

sodium  bicarbonate  in,  111 
Enterocolitis,  315 

Enteroteratomata  of  umbilicus,  139 
Entozoa,  337 
Enuresis,  446 

definition  of,  447 

diurnal,  447 

prognosis  in,  448 

treatment  of,  448 
Environment,  change  of,  for  child,  118 

in  development  of  speech,  34 
Eosinophilic  leucocytes  in  children,  2 
Epidemic  cerebrospinal  meningitis,  467 

encephalitis,  494 

clinical  picture  of,  495 
diagnosis  of,  496 
etiology  of,  496 
treatment  of,  496 

infantile  paralysis,  acute,  510 

meningitis,  coryza  in,  349 

parotitis,  684 
Epidemics,  origin  of,  575 
Epidemiology   of   meningococcus    menin- 
gitis, 467 

Epidermolysis  bullosa,  829 
Epididymis,  tuberculosis  of,  735 
Epidural  hemorrhage,  prognosis  of,  129 
Epilepsia  cursiva,  545 
Epilepsy,  545 

aura  in,  545 

bromides  in,  549 

bromidism  in,  549 

cerebral  hemorrhage  in,  130 

course  of,  547 

cursiva,  545 

diagnosis  of,  547 

foaming  at  mouth  in,  546 

grand  mal  in,  545,  547 

intermittent,  547 

nodding,  545 

of  infancy,  541 

petit  mal  in,  545,  547 

psychic  equivalents  in,  545 

salaam  spasm  in,  545 

symptomatic,  545 

termination  of,  547 

treatment  of,  548 

true,  545 

typical,  545 

uninterrupted,  547 
Epileptiform   convulsions   in   tuberculous 

meningitis,  463 
Epinephrin  in  acute  coryza,  39 

in  alimentary  intoxication,  297 

in  sepsis,  148 

stimulating  action  of,  109 

to  nose  in  disturbance  of  respiration  due 
to  obstruction,  110 


Epistaxis,  354 
in  hemophilia,  354 
in  infantile  scurvy,  187 
in  leucemia  354, 
in  measles,  605 
in  pertussis,  354, 
in  typhoid  fever,  354,  691,  693 
Epithelial  growths,  benign,  842 

pearls  in  stomatitis,  242 
Epithelioma  contagiosum,  848 
Epstein 's  rocking  chair  for  scoliosis,  102 

in  rickets,  205 
Erb's  phenomenon,  530 
point,  131 

type  of  paralysis  of  brachial  plexus,  131 
Erepsin,  9 
Erethismic  habitus,  734 

in  scrofula,  734 

Ergines,  tuberculous,  735,  737,  739 
Erupting  teeth,  order  of,  30 
Erysipelas,  713 
age  in,  713 
breast  feeding  contraindicated  in  severe, 

37 

broncho-pneumonia,  in,  714 
circumcision  and,  713 
clinical  course  of,  713 
complications  of,  714 
definition  of,  713 
diagnosis  of,  714 
etiology  of,  713 
in  malnutrition,  299 
mother's  milk  in,  715 
of  new-born,  149 

alcohol  externally,  in,  149 

aluminum  acetate  in,  149 

differentiation  from  phlegmon,  149 

fever  in,  149 

genital  origin  of,  149 

ichthyol  in,  149 

magnesium  sulphate,  external  appli- 
cations of,   in,  149 

mercuric  chloride  in,  149 

mother's  milk  in,  149 

prognosis,  unfavorable  in,  149 

sequelae  of,  149 

stimulants  in,  149 

umbilical  origin  of,  149 
prophylaxis  of,  715 
streptococcic,  713 
treatment  of,  715 
vaccination  and,  713 
wound,  713 

Erythema,  annulare,  809 
contusiforma,  809 
drug,  810 

exudativum  multiforme,  809 
hemorrhagicum,  809 
infectious,  620,  810 
iris,  809 
localized,  809 
margin  atum,  809 
measles,  810 
multiforme,  809,  810 
multiple,  809 


INDEX 


871 


Erythema  neonatorum,  physiologic,  13 

nodosum,  728,  809 

noxious  agent  in,  810 

papulatum,  809 

post-vaccinational,  810 

scarlatinal,  810 

serum,  810 

toxic,  810 

tuberculin,  810 

tuberculatum,  809,  810 

erythema  urticatum,  803 

vesiculosum,  809 

Erytheme  syphiloide  posterosiv,  794 
Erythroblasts,  157,  158 

primary,  156 
Erythrodermia,  795 

desquamatative,  795 
Erythropoiesis,  causing  anemia,  161 

compensatory,  160 
Erythropoietic  tissues,  pathologic  changes 

in,  160 

Esophagitis,  corrosive,  254 
strictures  in,  254 

diagnosis  of,  254 

treatment  of,  254 
Esophagus,  acquired  diseases  of,  254 

atresia  of,  254 

congenital  anomalies  of,  254 

d'Espine's  sign,  726 

diseases  of,  247 

diverticula  of,  254 

stenoses  of,  254 

strictures  in,  254 

Ether  preferable  to  chloroform  for  chil- 
dren, 119 
Ethyl  carbamate  in  purulent  meningitis, 

467 

Ethylhydrocuprein  in  meningitis,  467 
Eunuchoidism,  235,  236 
Eustachian  tubes,  diseases  of,  355 
Examination,  technic  of,  Chapter  III,  p.  70 
Exanthemata,  acute,  spread  of,  99,  100 
Excoriation  of  umbilicus,  137 
Exercise,  lack  of,  in  children,  212 
Exogenous  diseases,  303 
Exploratory  puncture  of  pleura,  388 
Extensor  surfaces,  prurigo  of,  807 
Extremities,  short  plump,  in  rickets,  192 
Exudate  in  meningococcus  meningitis,  468 

in  purulent  meniningitis,  465 

in  serous  meningitis,  474 
Exudative  dermatoses,  825 

children,  care  of,  102 
Exudative  diathesis,  214,  305,  730,  731 
anesthesia  in,  217 
atropin  in,  219 
chafing  in,  216 
death,  sudden,  in,  217,  218 
diagnosis  of,  218 
diet  in,  223 
duration  of,  218 
eczema  in,  216,  217 
endocrine  organs,   deficiency  of,  in, 

219 
familial,  214 


Exudative  diathesis,  geographical  tongue 
in,  217 

habitus  of,  215 

hereditary,  214 

impetiginous  eczema  in,  217 

infantilism  in,  215 

initial  appearances  of,  214 

intertrigo  in,  216 

laryngospasm  in,  218 

lichen  in,  216 
strophulus,  216 
urticatus,  216 

lymp    nodes,  hyperplasia  of,  in,  215 
217,  219 

manifestations  of,  215 

metabolism  in,  217 

milk-crusts  in,  216 

occurrence  of,  214 

of  lymphatic  organs,  215 

of  mucous  membranes,  215 

of  skin,  215 

operative  shock  in,  224 

overfeeding  in,  220 

"pasty"  habitus  in,  215 

pluriglandular  insufficiency  in,  219 

primary  forms  of,  215 

prurigo  in,  216 

psychic  treatment  of,  224 

Rachmilewitsch 's  mustard  test  in,  218 

scrofula  and,  225 

seborrho3a  in,  216 

secondary  forms  of,  215 

sequels  of,  215 

status  thymico-lymphaticus  of,  215, 
217,  220,  224 

tetany  in,  218 

theories  of,  218 

thymus,  hyperplasia  of,  in,  215,  217 
status  thymico-lymphaticus  in,  215. 
217 

tongue,  follicles  of,  in,  218 

tonsils,  hypertrophy  of,  in,  215,  217 

treatment  of,  223 

ultimate  nature  of,  218 

uric  acid  diathesis,  and,  221 

urticaria  rubra  in,  216 

vaccination  in,  220 

vagus  hypertonia  in,  219 

vegetable  diet  in,  223 

White  first  described,  214 

X-rays  in  diagnosing,  218 
Eyes,  Crede's  method  of  protecting,  at 

birth,  150 
examination  of,  75 

ophthalmoscopic,  75 
hyperopic,  at  birth,  32 
in  measles,  601,  609 
in  meningococcus  meningitis,  468,  470 
scrofula  of,  731,732,  733 
syphilis  of,  770,  777 
washing  of,  66 

FACIAL  mimicry,  33 
paralysis,  133,  528 
causes  of,  133 


872 


INDEX 


Facial  paralysis,  diagnosis  of,  133 
prognosis  of,  133 
symptoms  of,  133 
treatment  of,  133 
Facies,  tetanic,  142 
Factor,  Budin's,  63 
Fainting  spells,  490 

of  babe  during  breast-feeding,  306 
Family  history,  70 

idiocy,  amaurotic,  523 

juvenile,  523 
Farina  mixture,  272 
Faroe  Islands  measles  statistics,  599 
Fat,  absorbed,  uses  of,  17 

absorption  of,  in  infants,  17 

caloric  value  of,  20 

catarrh,  aggravated,  by  too  much,  101 

metabolism,    acetone    bodies    in    urine 

from  disturbances  of,  18 
physiology  of,  15 

metabolized  per  body-weight,  64 

milk,  5 

neutral,  16 

percentage  of,  in  milk,  4,  5 

reducing  nitrogen  absorption,  16 

sclerema  in  alimentary  intoxication,  293 

soluble  A  vitamin,  preventing  rickets, 
196 

stained  by  carbol-fuchsin,  273 

subcutaneous,  14 
Father's  responsibility  to  illegitimate  child, 

104 
Fattening,  dangers  of,  65 

excessive,  to  be  avoided,  65 
Fatty  acids,  free,  16 
in  milk,  5 
volatile,  in  milk,  5 
Favus,  834 
Feces,  characteristics  of,  11 

fat  in,  17 

volatile  fatty  acids  in,  17 
Feeble-mindedness,  567 

diagnosis  of,  569 

etiology  of,  567 

symptoms  of,  567 

treatment  of,  569 
Feeding,  artificial,  54 
dangers  from,  54 

calculating  amount  of  water  in,  64 

critical     drop     in     temperature     upon 
cessation,  295 

definition  of  proper,  36 

four-hour,  in  new-born,  46 

improper,  cause  of  school  fatigue,  105 

intervals  between,  46 

mixed,  49,  50 

normal,  36 

number  of,  from  breasts,  46 

of  premature  children,  123 

of  the  normal  infant,  Chapter  II,  p.  36 

of  underweight  infants,  65 

result  of  proper,  65 

science  of,  36 

stomach  tube  for,  113 

summary  of  infant,  64 


Feeding,  weight  increase,  test  of,  48 
Feer  E.:    Acute  infectious  diseases,   Part 

VIII,  p.  571 

Diseases  of  the.  heart,  Part  V,  p.  389 
Feet,  wet,  care  of,  67 
Female  generative  organs,  tuberculosis  of, 

735 

Fermentation  antagonistic  to  putrefaction, 
12 

injury,  259 

Ferments  in  milk,  6,  7 
Ferrum  reductum  in  treatment  of  Czerny  's 

anemia,  173 
Fetal  infection  of  tuberculosis,  720 

peritonitis,  345 

pertussis,  673 

rickets,  204 

Fetor  ex  ore  in  diphtheria,  642 
Fetus,  storing  up  of  iron  salts  in,  1 

water  contents  of,  1 
Fever,  acetylsalicylic  acid  in,  107 

alcohol  in,  to  be  avoided,  107,  109 

alimentary,  262,  263 

antipyretics,  in,  107 

antipyrin  in,  107 

baths  in,  106 

blisters,  826 

dimethyl-amido-antipyrin  in,  107 

dissipation  to  be  increased  in,  106 

enemata  in,  107 

food,  avoidance  of,  in,  106 

glandular,  250 

in  infantile  scurvy,  188 

in  intoxication,  292 

in  spasmophilic  children,  108 

local  treatment  of,  106 

lymphatic  children,  108 

paratyphoid,  698 

quinine  derivatives  in,  107 

quinine  in,  107 

scarlet,  579 

treatment  of,  106 

typhoid,  688 

Fibroma  lipomatodes,  849 
Fifth  disease,  810 
Financial  assistance  to  children,  104 

to  mothers,  104 
Finger,  drumstick,  726 
Finger-nails,  growth  of,  impaired  in  scarlet 

fever,  584 
Finkelstein,  H.:   Diseases  of  the  digestive 

system,  Part  III,  p.  242 
Diseases  of  the  new-born,  Part  I,  p.  121 
Finsen  rays  in  lupus,  821 
First  dentition,  30 

Fishmouth  in  tonic  convulsions,  536 
Fishskin  disease,  844 

congenital  nature  of,  844 
treatment  of,  846 
Fissured  nipples,  38 

anesthesin  ointment  in,  38 
antiseptic  drying  powder  in,  38 
balsam  of  Peru  for,  38 
bandaging  of  breast  in,  38 
bismuth  subgallate  for,  38 


INDEX 


873 


Fissured  nipples,  black  salve  in,  38 
emptying  of  milk  in,  38 
glycerin  for,  38 
glycero-tannin  for,  38 
naphthalin  ointment  for,  38 
nipple-shield  for,  38 
silver  nitrate  for,  38 
Fistula  due  to  persistence  of  urachus,  135 

of  umbilicus,  135,  137 
Fits,  quiet,  535, 
Flail-joint  from  brachial  plexus  paralysis, 

132 

"Flea-bite"  encephalitis,  492 
Fleischner,   E.  C.:    The  acute  infectious 

diseases,  Part  VIII,  p.  571 
Flora  of  digestive  tract,  11,  12 
Flour,  baked,  62 

calories  of,  62 

digestion  of,  9 

dystrophy,  269 

in  infant  feeding,  60,  61,  63 

in  intestinal  infections,  319 

mineral  matters  in,  61 

paste,  269 

soups,  290 

stools,  274 

toasted,  62 

Flour-feeding  of  Czerny  and  Keller,  269 
Fliigge's  cooling  box  for  milk,  57 
Foaming  at  mouth  in  epilepsy,  546 
Follicular  angina,  249 

enteritis,  315 

Fontanelles,  greater  or  anterior  only  open 
at  birth,  29,  480 

in  hydrocephalus,  478,  480 

in  meningococcus  meningitis,  470,  472 

in  premature  children,  125 

in  purulent  meningitis,  466 

in  rickets,  29 

in  serous  meningitis,  475 

in  tuberculous  meningitis,  463 

parietal,  open  pathologically  only,  29 

size  of,  measuring,  72 

smaller  or  posterior,  open  pathologic- 
ally, only,  29 

tension  of,  estimating,  72 

ventricular  puncture  through,  in  menin- 
gococcus meningitis,  474 
Food  diseases,  19 

ingested  in  relation  to  body-weight,  59 

interchangeability  of,  20,  21 

proprietary,  59,  62 

spices,  strong,  not  to  be  given,  66 

substances,  accessory,  19 

time  for  passing  through  intestines,  1 1 

urticaria,  caused  by,  804 
Foramen  ovale,  patent,  397 
Forearm  type  of  paralysis  of  the  brachial 

plexus,  131 

Foreign  bodies  in  bronchial  tubes,  363 
in  ear,  360 
in  nose,  354 

Forlanini's  nitrogen  insufflation,  747 
Four-hour  feeding  of  new-born,  46 
Fourth  disease,  Dukes',  594,  622,  810 


Fowler's  solution  in  treatment  of  anemia, 

173 
Fractures,  birth,  132 

in  infantile  scurvy,  186 

in  osteogenesis  imperfecta,  237 

in  rickets,  199 

X-rays  of,  238 
Frail  children,  211 
Frailness,  degenerative  form  of,  213 
Free  fatty  acids  in  stools,  17 
Friedlaender's  bacillus  in  sepsis  of  new- 
born, 144 

Friedreich's  ataxia,  525 
Fructose,  17 

Fruits,  fresh,  in  infantile  scurvy,  190 
Functional  tests,  419 
Fundus  of  eyes  in  tuberculous  meningitis 

462 

Fungus  of  umbilical  stump,  135,  139 
Furunculosis,  814 

in  malnutrition,  299 

treatment  of,  815 

vaccines  in,  815 
Fusiform  bacillus,  251 

in  ulcerative  stomatitis,  245 

GAG,  mouth,  74 
Gagging  reflex,  72 
Galactagogues,  40 

specific,  41 
Galactorrhcea,  40 
Galactose,  293 

from  milk-sugar,  17 
Galactosuria,  208 

Gall-bladder,  typhoid  infection  of,  688 
Gangrene  of  umbilicus,  135,  136,  146 
of  umbilical  stump,  136 
cautery  in,  136 
treatment  of,  136 
Gastric  bubble,  113 

contents,  examination  same  as  in  adult, 

90 

digestion,  duration  of,  10 
dilatation,  325 
fever,  315,  689 
icterus  in,  315 
in  acute  dyspepsia,  308 
lavage,  112 
motility,  80 
Gastro-enteritis,  314 
Gastro-intestinal  catarrh,  chronic,  308 
diseases,  causing  one-third  of  infant  mor- 
tality, 94 
nervous,  322 
form  of  sepsis,  146 
tract,  acute  infectious  diseases  of,  314 

sterility  in,  effects  of,  12 
tuberculosis,  320,  720,  721 
Gastrp-paresis  in  chronic  dyspepsia,  309 
Gelatin    treatment    of     internal     hemor- 

rhagic  pachymeningitis,  458 
of  melena,  149 

of  purpura  hemorrhagica,  185 
of  umbilical  hemorrhage,  144 
General  considerations,  Chapter  I,  p.  1 


874 


INDEX 


General  miliary  tuberculosis,  458 
pathogenesis,  Chapter  IV,  p.  86 
prophylaxis    and  therapy,  Chapter  V, 

p.  98 

symptomatology,  Chapter  III,  p.  70 
therapy,  106 

Genitals,  external,  examination  of,  71 
Genito-urinary  system,  diseases  of,  Part  VI 

p.  419 

tract,  tumors  of,  455 
Genu  valgum  in  rickets,  200 

varum  in  rickets,  200 
Geographical  tongue,  217 
German  Empire,  statistics  of  birth,  still- 
births and  deaths  in,  87,  88 
measles,  616 

Germinal  organs,  pathology  of,  235 
Giant  cells,  of  blood,  156 

urticaria,  805 
Gibbous,  tuberculous  meningitis  following 

straightening  of  a,  458 
Giemsa  method,  150 
Girls,  weight  increase  of,  26 
Glands  of  internal  secretion,  pathology  of, 

226 

Glandular  fever,  250 
definition  of,  250 
diagnosis  of,  250 

differentiation  from  scarlet  fever,  250 
relation  to  grippe,  250 
treatment  of,  251 
Globulin,  4 

Glomerulo-tubular  nephropathy,  434 
etiology  of,  435 
prognosis  of,  435 
symptoms  of,  435 
treatment  of,  435 
Glottis,  spasm  of,  in   spasmophilia,    533, 

534 

Glucose  from  milk-sugar,  17 
Glycerin  enemata,  1 12 

in  acute  dyspepsia,  308 
esters  in  milk,  5 
in  fissured  nipples,  38 
suppositories,  112 

Glycero-tannin  in  fissured  nipples,  38 
Glycogen,  water-holding  properties  of,  23 
Glycosuria  in  alimentary  intoxication,  292, 

293 

Goat,  keeping  of,  to  supply  milk,  56 
Goat's  milk,  composition  of,  4 
milk-sugar  contents  of,  5 
peculiarities  of,  4 
Go-cart,  misuse  of,  67 
"Going  in"  of  measles,  608 
Goitre,  234 

congenital,  234 
districts,  231 
iodin  in,  235 

trachea,  compressed,  by,  126 
treatment  of,  235 
Gonitis,  syphilitic,  777 
Gonococcic  infection  of  nose,  349 
Gonococcus in  ophthalmia  neonatonim,  150 
Gonorrheal  conjunctivitis,  150 


Gram-negative  diplococci  in  spinal  fluid 
in  meningococcus  meningitis,  468,  470, 
473 

Grand  mal  in  epilepsy,  545  547 
Granulated  sugar  in  infant  feeding,  60,  61 
Granuloma  of  umbilicus,  139 

treatment  of,  139 
pyogenicum,  834 
Granulomatosis,  182 

diazo-reaction  of  urine  in,  182 
excision  of  granulomata  in,  184 
iodin  in,  184 
localized  forms  of,  182 
malignant,  183 
symptoms  of,  182 
treatment  of,  184 
Gray  obstipation,  265 
Great  vessels,  transposition  of,  399 
Green  sickness,  163 

Grinding   of   teeth   in   tuberculous    men- 
ingitis, 460 
Grippal  diseases,  699 

broncho-pneumonia  in,  702 
causative  agent  in,  700 
contagiousness  of,  700 
cough  in,  701 
course  of,  703 
diagnosis  of,  704 

differential,  704 

differentiated  from  influenza,  699 
empyema  in,  702 
endemic,  699 
epidemic,  699 

febrile  respiratory  form  of,  704 
fever  in,  701,  702 

gastro-intestinal  symptoms,  in,  703 
isolation  of  those  affected,  705 
lobar  pneumonia  in,  702 
meningitis,  septic,  in,  702 
nervous  type  of,  703 
pandemic,  699 
pleurisy  in,  702 
pneumonia,  in  702 
predisposition  to,  701 
prodromes  in,  701 
prognosis  of,  704 
prophylaxis  of,  705 
symptoms  of,  701 
tonsils,  infection  of,  in,  701 
transmission  of,  700 
treatment  of,  705 
vomiting  in,  701 
Grippe,  la,  699 

relation  to  glandular  fever,  250 
Grippe-like  infection  of  new-born,  causing 

asphyxia,  126 
Growing  pains,  423 
Growth,  23 

disturbances  of,  236 
in  height,  27 
indices  of,  23 
skeletal,  29 
Gruels,  digestion  of,  9 
in  dyspepsia,  290 
in  infant  feeding,  61 


INDEX 


875 


Gruels,  thick,  61 

thin,  61 

Guarnier's  bodies  in  small-pox,  629 
Gummata,  775 
Gummatous  neoplasms,  774 
Gums  in  infantile  scurvy,  188 

HABITUS  "pasty,"  215 

phthisicus,  734 

Hair,  removal  of,  from  head,  84 
Hand,  obstetric  position  of,  531,  536 

trident,  237 
Hay  fever,  350 
Head,  circumference  of,  72 
cross-bun,  200 
examination  of,  72 
hair,  removal  of,  from,  84 
hematoma  of,  in  new-born,  127,  128,  129 
large,  in  rickets,  192 
louse,  815 
saddle,  200 
tower,  487 
Headache  in  acute  dyspepsia,  307 

in  meningococcus  meningitis,  468,  472 
in  purulent  meningitis,  466 
in  serous  meningitis,  475 
in  tuberculous  meningitis,  459,  465 
Health   Board   regulations  in   contagious 

diseases,  579 
normal,  262 

Heart,  anatomic  relations  of,  1 
arhythmia  of,  390 
auscultation  of,  76 

direct,  76 
block,  391 

congenital  diseases  of,  394 
asphyxia  in  126 
cyanosis  in,  394 

ductus  arteriosus,  patency  of,  397 
frequency  of,  394 
hyperglobulia  in,  395 
interventricular    septum,    defect 

of,  396 

morbus  coeruleus  of,  394,  395 
prognosis  of,  396 
pulminary  stenosis  in,  398 
respirations  in,  396 
treatment  of,  396 
diseases  of,  Part  V,  p.  389 
drop,  418 
dulness,  absolute,  75 

relative,  76 
examination  of,  75 
first  sound  of,  76 
hemodynamic  relations  of,  1 
in  acute  articular  rheumatism,  706 
in  chorea,  551 
massage  in  asphyxia,  126 
masturbation,  action  on,  418 
murmurs  of,  391 

rare  in  children,  76 
muscular  tone,  response  to,  415 
nervous  disturbances  of,  393 
palpitation  of,  393 
percussion  of,  75 


Heart,  pubertal,  2 

rhythm,  disturbances  of,  389 

second  sound  of,  76 

sounds,  auscultation  of,  72 

valvular  lesions  of,  392,  393 

weight  of,  in  adult,  1 
in  new-born,  1 
ventricles  at  birth,  1 
Heat  injury,  260,  261,  263 

immunity  to.  in,  the  breast-fed,  261 

production  decreased  by  quinine,  107 
in  normal  infants,  22 

radiation,  20 

summer,  causing  disease,  260 

stroke,  261 

value  of  milk,  4 
Heating  pads,  electric,  108 

burning  from,  108 
Hebephrenia,  570 

Hectic  flush  in  chronic  pulminary  tuber- 
culosis, 735 

in  tuberculous  meningitis,  459 
Hediosit  for  diabetics,  209 
Height,  growth  in,  27 

periods  of  increase  in,  27 

relation  to  weight,  26 

seasonal  increase  in,  27,  28 
Heim-Johns '  solution,  296 
Heme-Medin  's  disease,  510 
Hematogenous  icterus,  166,  171 
Hematoma  of  head  in  the  new-born,  127, 
128,  129 

of  sternocleidomastoid,  130 
wry  neck  from,  130,  131 
therapy  of,  131 
Hematuria,  444 

in  infantile  scurvy,  187 
Hemichorea,  551 
Hemicrania,  556 

Hemi-encephalic  infants,  taste  in,  33 
Hemiplegia  in  tuberculous  meningitis,  463 

spastic  infantile,  499,  501 
Hemocytolysis,  from  acetanilid,  166 

from  acetphenitidin,  166 

from  anilin  derivatives,  168 

from  antifebrin,  166 

from  lactophenin,  166 

from  phenocoll,  166 

from  phenol,  166 

from  phenolphthalein,   166 

from  potassium  chlorate,  166 

from  pyrogallol,  166 
Hempcytolytic  anemia.  165 

poisons,  166 

Hemodynamic  relations  of  heart,  1 
Hemodynamics,  159 

Hemoglobin,  carbon  monoxide,  action  on, 
166 

hydrocyanic  acid  action  on,  166 

hydrogen  sulphide,  action  on,  166 

index,  159 

percentage  of,  in  new-born,  2 
Hemoglobinemia,  166 

in  Winckel's  disease,  146 
Hemoglobinuria,  166,  444 


876 


INDEX 


Hemoglobinuria,  paroxysmal,  171 
Hemoptysis,  early,  in  pulmonary  tuber- 
culosis, 735 
Hemorrhage,  cerebral,  of  new-born,  129 

asphyxia  from,  126 

due  to  multifocal  infectious  diseases,  185 
epidural,  129 
of  umbilicus,  143,  144 
of  uterus  in  new-born,  154,  155 
retinal,  in  internal  hemorrhagic  pachy- 

meningitis,  457 
tendency  to,  184 
Hemorrhagic  arthritis,  185 
articular  pains,  in,  185 
cutaneous  purpura  in,  185 
intestinal  colic,  in,  185 
joints,  swelling  of,  in,  185 
rest  in  bed  in,  186 
treatment  of,  186 
diathesis,  168,  184 
bleeding  time  in,  128 
cerebral  hemorrhage  from,  129 
coagulation  time  in,  128 
in  lymphosarcomatosis,  179 
of  new-born,  126 

idiopathic,  144 
form  of  sepsis,  146 
pachymeningitis,  477 
internal,  457 

rhinitis  in,  457 
rhinitis  in  diphtheria,  457 

in  syphilis,  457 
Hemosiderin,  storage  of,  166 
Hepatitis  from  lymphangitis  of  umbilical 

vein,  141 

Herb  tea  in  colic,  115 
Hereditary  ataxia,  525 

diagnosis  and  treatment  of,  526 
of  Werdnig-Hoffmann,  210 
leanness,  212,  213 
neuropathy,  553 
taint,  converging,  98 

in  tuberculosis,  735 

Heredito-alaxie  cerebelleuse  of  Marie,  525 
Heredito-degenerative  diseases,  522 
Heredito-familial  diseases,  522 
Hernia,  336 

diaphragmatic,  126,  337 

asphyxia  of  new-born  from,  126 
inguinal,  336 
of  umbilical  cord,  134 
contents  of,  134 
dangers  of,  134 
diagnosis  of,  134 
treatment  of,  135 
umbilical,  337 
vaginal,  funicular,  337 
Herpes,  826 
aestivalis,  829 
febrilis,  826 

in  meningitis,  468,  469,  472 
labialis,  826 
simplex,  826 

definition  of,  826 
differential  diagnosis  of,  826 


Herpes,  simplex,  etiology  of,  826 
symptoms  of,  826 
treatment  of,  826,  827 
tonsurans  maculosus,  831 
zoster,  827 

treatment  of,  827 

Hess,  Julius:  Care  and  feeding  of  the  nor- 
mal infant,  Chapter  II,  p.  36 
Heubner's  disease,  342 

method  of  feeding  by  calories,  21 
Hexamethylenamine   in    meningitis,    467. 

473,  476 

Hip-joint,  operation  on,  followed  by  tuber- 
culous meningitis,  458 
Hirschsprung  's  disease,  330 
History,  family,  70 

of  case,  70 
Hoffmann,  Walter  H.  O.:   Diseases  of  the 

respiratory  organs,  Part  IV,  p.  347 
Homatropin,  in  examination  of  eyes,  75 
Home  pasteurization,  57 
Hoobler,    B.    Raymond:     Mortality    and 

morbidity,  Chapter  IV,  p.  86 
Hormone  secretin,  10 
splenic,  167 

stimulating  lactation,  14 
Horse  dandruff  coryza,  350 

serum  in  purpura  hemorrhagica,  185 

causing  serum  disease,  665,  666 
Hot  baths  for  premature  children,  121 

in  meningitis,  473,  476 
compresses  in  abdominal  pain,  115 
water  bottles,  122 

dangers  from  scalding,  by  108 
in  treatment  of  subnormal  temper- 
ature, 108 

Human  blood-cells,  groups  of,  156 
milk,  calcium  salts,  in,  51 
caloric  value  of,  22 
composition  of,  4 
in  rickets,  203 
iron  amount,  small  in,  161 
milk-sugar  contents  of,  5 
peculiarities  of,  4 
proteins  of,  10 
Hunger  period,  in  alimentary  intoxication, 

296 

effects  of,  on  lactation,  42 
"Hunted  beast"  respiration  in  alimentary 

intoxication,  292 
Hutchinson's  teeth,  777 

triad,  777 

Huntington's  chorea,  528 
Hydrencephaly,  483 
Hydroa  vacciniforme,  829,  830 
Hydrocele,  453 

Hydrocephalic  cry  in  tuberculous  menin- 
gitis, 461 
Hydrocephaloid,  476 

type  of  alimentary  intoxication,  294 
Hydrocephalus,  acquired,  477 
acute  internal,  457,  477 
chronic  internal,  477 

cerebrospinal  fluid  in,  480 
clinical  picture  of,  478 


INDEX 


877 


Hydrocephalus,  chronic  internal,  course  of, 

479 

diagnosis  of,  481 
differential,  482 

from  serous  meningitis,  475 
etiology  of,  477 
pathogenesis  of,  477 
pathologic  anatomy  of,  478 
prognosis  of,  482 
symptoms  of,  479 
termination  of,  479 
treatment  of,  482 
ventricles,  puncture  of,  in,  483 
congenital,  477 

asphyxia  of  new-born  in,  126 
e  vacuo,   483 
external,  477 

fluid  from,  84 

in  meningitis,  471,  472,  473,  475 
in  premature  children,  125 
internal,  resemblance  to  internal  hemor- 

rhagic  pachymeningitis,  457 
Hydrochloric  acid,  antiseptic  action  of,  9 

dilute,  117 
Hydrocyanic  acid,  action  on  hemoglobin, 

'166 
Hydrogen  sulphide,  action  on  hemoglobin, 

'166 

Hydronephrosis,  congenital,  456 
Hydrotherapy  in  intestinal  infections,  319 
in  treatment  of  chlorosis,  174 
of  fever,  106,  107 
of  secondary  anemias,  174 
of  typhoid  fever,  697 
Hygiene  of  nursing  mother,  41 
Hygroma  of  the  dura  mater,  457 
Hyperemia  for  mastitis,  38 
Hyperesthesia  in  meningitis,  459,  472 
Hyperglobulia  in  congenital  heart  lesions, 

'395 

Hypernephromata,  456 
Hvperplasia  in  intestinal  polyposis,  321 
of  tonsils,  252 
osteoid,  in  rickets,  196 
Hyperpyrexia,  in  alimentary  intoxication, 

292 

hydrotherapeutics  measures  in,  106,  107 
in  tetanus,  142 
Hyperthermia,  260 
Hyperthyreosis,  226 
Hypertonia,  34 

general  muscular,  without  spasmophilia, 

543 

Hypertrophic  stenosis  of  the  pylorus,  322 
Hypertrophies  of  skin,  843 
Hypertrophy  of  breasts,  47 
Hypodermoclysis,  111 
Hypogenesis  ossium,  in  rickets,  196 
Hypogenitalism,  235 

in  endemic  cretinism,  232 
Hypophysis,  injury  to,  in  serous  meningitis 

475 

pathology  of,  236 
Hypopituitarism,  236 

in  endemic  cretinism,  232 


Hypopituitarism,  treatment  of,  236 
Hypothyreosis,  226 

abortive  infantile,  233 

bone,  effects  of,  on,  227 

cachexia  thyreopriva,  227 

congenital  myxedema  in,  226 

cretinism  in,  227 

dentition,  disturbances  of,  in,  227 

diathesis  of,  227 

dwarfism  in,  227 

endemic  cretinism,  227 

metabolic,  changes  in,  230 

mucous  membranes,  changes  of,  in,  228 

muscles,  affections  of,  in,  229 

parathyroids  in,  227 

psychic  anomalies  in,  229 

skeleton  in,  227 

skin,  changes  of,  in,  228 

sporadic  forms  of,  227 
Hypotonicity,  gastro-paresis  in,  309 
Hypotrophy,  264 
Hysteria,  562 

diagnosis  of,  564,  565 

manifestations  of,  563 

monosymptomatic,  558 

recognition  of,  564 

treatment  of,  565 

I.  U.,  IMMUNITY  unit,  661,  667 

Ibrahim,    J.:     Diseases    of    the    nervous 

system,  457 

Ibrahim 's  breast  pump,  45 
Ice  applications  in  mastitis,  38 

in  meningococcus  meningitis,  473 
in  purulent  meningitis,  467 
Ice-cap,  danger  of,  in  children,  107 
Ichthyol  albuminate  for  anorexia,  117 
in  eczema  of  nipples,  46 
in  erysipelas,  149 
Ichthyosis,  844 

palmaris  et  plantaris,  844 
Icterus,  chronic  familial  hemolytic,  171 
gravis,  habitual,  153 
hematogenous,  166 
in  gastric  fever,  315 
in  sepsis  of  new-born,  146 
lymphangitis  of  umbilical  vein,  141 
neonatorum,  151 

autopsy  findings  in,  158 
epidemic  forms  of,  153 
etiology  of,  152 
feces  in,  151 
frequency  of,  151 
maladie  bronzee,  153 
masses  jaunes,  in  urine  of,  151 
pathologic,  151,  152 
physiologic,  151,  152 
sclera  in,  151 
septic  forms  of,  153 
theories  of,  152 
urine  in,  151 
Idiocy,  567 

amaurotic  familial,  523 

juvenile,  523 
in  asphyxiated  children,  126 


878 


INDEX 


Idiocy  in  premature  children,  125 
from  cerebral  hemorrhage,  130 
from  meningococcus  meningitis,  471,  473 
mongolism-mpngoloid,  239 
brain,  atypical,  in,  240 
distribution  of,  238 
habitus  of,  239 
music,  love  of,  in,  240 
skeleton  in,  240 
somatic  indication  of,  241 
thyroid  feeding  in,  241 
treatment  of,  241 

mongoloid,  mistaken  for  rickets,  204 
Tay-Sachs',  523 

mistaken  for  rickets,  204 
Idiopathic  morbus  Werlhoffi,  184 
Idiosyncrasies  in  diseases  due  to  endogen- 
ous causes,  306 
Idiots,  agile,  568 
facial  mimicry  in,  33 
torpid,  568 
versatile,  568 
Illegitimate  child,   father's  responsibility 

to,  104 
unfavorable    position    of,    in    infant 

mortality,  88,  89,  93,  94 
Imbecility,  567 
definition  of,  568 
signs  of,  33 

Immune  bodies  in  milk,  6,  7 
Immunity  after  contagious  diseases,  574 
of  breast-fed  infants  from  heat  injury,  261 
unit,  I.  U.,  661,  667 
Impetigo,  811 
contagiosa,  811 
ecthyma  in,  811 
pustule  in,  811 
secondary,  811 
treatment  of,  812 
Inanition  in  children,  211,  259 
Incisors,  first  teeth  to  appear,  30 

in  syphilis,  777 

Inclusion  bodies  in  blennorrhoea,  150 
Incubation  room  for  premature  children,  122 
Incubator  anemia,  162 

for  premature  children,  122 
for  subnormal  temperature,  108 
India  ink  method  of  staining  spirochaetes, 

750 
Inequality    of    pupils    in    meningococcus 

meningitis,  470 
Infant,  anencephalic,  33 

artificially-fed,    table   showing   average 

weight,  first  year,  25 
blood  in,  2 
cells  of,  2 

eosinophilic,  in,  158 
hemoglobin  of,  2 
hemoglobin,  percentage  in,  158 
lymphocytes  of,  158 
polymorphonuclear  cells  of,  158 
red  cells  per  cubic  millimeter  of,   158 
sugar  of,  18 

white  cells  per  cubic  millimeter  of,  158 
body  temperature  of,  14,  20 


Infant,  breast-fed,  table  showing  average 

weight,  first  year,  25 
coordinated  muscular  movements  in,  32 
disease-picture  in,  70 
fat,  absorption  of,  in,  17 
feeding  of,  see  infant-feeding  below 
heat  production  in,  22 
hemi-encephalic,  33 
intake  of  food  in,  20 
life  of,  first  month  most  critical  in,  89 
mineral  constituents  of,  18 
morbidity,  103 
mortality,  103 

in  Berlin  1900  to  1902,  90 
nervous  system  of,  31 
nitrogen  retention  of,  16 
normal,  care  of,  Chapter  II,  p.  36 

feeding  of,  Chapter  II,  p.  36 
nutritional  disturbances  of,  255 
output  of  food  in,  20 
skin  of,  13 
sleep  of,  35 

position  in,  35 

stomach  of,  development  of,  8 
speaking,  time  of  first,  34 
stools  of  breast-fed,  11 
suckling  by,  44 
taste  in,  33 
temperature  of  body  in,  14,  15,  20 

maintenance  of  normal,  67 
urinary  bladder,  location  of,  in,  13 
water,  function  of,  in,  18 

excretion  in,  19 
welfare  work,  91 
Infant-feeding,  Chapter  II,  p.  36 
barley  in,  61 
Budin's  factor  in,  63 
"butter-flour"  mixture  in,  60 
cane-sugar  in,  60,  61 
condensed  milk  in,  62 
corn  flour  in,  61 
cream  in,  59 
fat  variations  in,  16 
flours  in,  60,  61,  63 
gruels  in,  61 
malt  extract  in,  61 

sugar  in,  61 
maltose  in,  61 
milk  in,  55 
oatmeal  in,  61,  63 
rice  in,  61 
rolled  oats  in,  61 
salt  in,  61 
starch  in,  65 
sugar  in,  60,  61,  64 

of  milk  in,  58,  60,  61,  62 
underweight  child  in,  65 
wheat  flour  in,  61 
Infantile  cerebral  palsy,  499 
liver,  340 

nuclear  atrophy,  488 
spinal  paralysis,  acute,  510 

causative  agent  of,  51 1 
clinical  picture,  of,  512 


INDEX 


879 


Infantile  spinal   paralysis,    acute,   course 
of,  512 
diagnosis  of,  517 

differential,  517 
epidemic,  510 
epidemiology  of,  510 
etiology  of,  510 
mistaken  for  rickets,  204 
organism  of,  511 
paralysis  in,  513 
pathologic  anatomy  of,  511 
prognosis  of,  518 
symptomatology  of,  512 
treatment   of,  519 
scurvy  (Barlow's  disease),  186 
age  of  child  in,  189 
anemia  in,  186,  188 
appetite  in,  188 
apples  in,  190 

artificial  feeding,  causing,  189 
bleeding,  conjunctival,  in,   187 

intestinal,  in,  187 

nasal,  in,  187 

urinary,  in,  187 
blood  in,  188 

cephalhematomata  in,  188 
course  of,  189 
diagnosis  of,  186 
deformities  in,  186,  i87,  188 
differentiation  from  rickets,   186 
enteritis  in,  189 
etiology  of,  186,  189 
fever  in,  188 
fruit,  fresh,  in,  190 
grape  juice  in,  190 
gums  in,  188 

softening  of,  in,  187 
heart  in,  188 
hematuria  in,  187,  188 
hemorrhage,  tendency  to,  in,  186 

187,  188,  190 
knees,  swelling  of,  in,  188 
lemons  in,  190 

males  especially  affected,   189 
meat  juices  in,  190 
milk,  raw,  in,  190 
nutrition,  disturbance  of,  in,  189 
occurrence  of,  189 
onset  of,  189 
oranges  in,  190 
osteotabes  in,  186 
pain  in,  188 
pneumonia  in,  189 
predisposition  in,  189 
prognosis  of,  189 
pseudoparalysis  in,  186,  188 
silicic  acid,  not  a  cause  of,  189 
sternum,  sinking  in  of,  in,  187 
stools,  bloody,  in,  187 
symptoms  of,  186 
therapy  of,  190 
vegetables  in,  190 
X-rays  in,  188 
Infantilism,  233 
anemia  in,  161 


Infantilism,  Brissand-Hertogh  type  of,  233 

Lorrain  type  of,  233 

genital,  causing  obesity,  210 

in  exudative  diathesis,  215 
Infarcts,  uric  acid,  13,  154 
Infection,  259 

diet  in,  300 

exhaustion  from,  302 

from  schools,  105 

migratory,  140 

milk,  260 

nutrition  and,  299 

of  umbilicus,  135,  136 

parenteral,  291,  304 

weight,  loss  of,  from,  302 
Infections,  pachy meningitis,  457 
Infectious  diseases,  acute,  Part  VIII,  p.  571 
aspiration  infection  in,  573 
combination  of  two  or  more,  576, 

577 

contact  infection  in  573 
contagion  index  for,  574 
convalescence  from,  577 
diatheses,  effects  of,  on,  577 
disposition  to,  574 
droplet  infection  in,  572,  573 
duration  of  infection  in,  579 
effects  of,  on  tuberculosis,  722 
general  consideration  of,  571 
Health  Board  regulations  in,  579 
hemorrhage  due  to  multifocal,  185 
immunity  after,  574 
isolation  in,  578 
opportunity  of  infection  in,  576 
origin  of  epidemics  in,  575 
pathogenesis  of,  572 
physician 's  duties  in,  578 
predisposition  in,  574 
prognosis  of,  577 
prophylaxis  of,  577 
rickets,  effects  of,  on  577 
serumtherapy  in,  572 
State 's  duties  in,  578 
transmission  of,  572 

erythema,  620 
diagnosis  of,  622 
exanthem  in,  621 
incubation  period,  620 
synonyms  of,  620 
Inflammations  of  skin,  830 
Inflammatory  diathesis,  214 
Influenza,  699 

abscess,  pulmonary,  in,  702 

bacillus  of  Pfeiffer'in,  700 

constitutional  disturbances  in,  702 

contagiousness  of,  700 

cough  in,  701 

course  of,  703 

diagnosis  of,  704 
differential  704 

differentiation  from  la  grippe,  699 

dyspepsia,  acute,  in,  308 

empyema  in,  702 

etiology  of,  700 

fever  in,  701,  702 

gastro-intestinal  symptoms  in,  703 


880 


INDEX 


Influenza,  heart  action  in,  703 

hemorrhages  in,  185 

isolation  of  those  affected  with,  705 

laryngitis  in,  701 

meningitis,  septic,  in,  702 

myringitis,  hemorrhagic,  in,  702 

nervous  type  of,  703 

of  1889-91,  699 

of  1891-3,  701 

of  1918,  700 

Pfeiffer's  bacillus  in,  700 

pleurisy,  fibrinous,  in,  702 

pneumonia  in,  702 

predisposition  to,  701 

prognosis  of,  704 

prophylaxis  of,  705 

respiratory  form  of,  701 

Spanish,  699 

sudden  onset  in,  701 

symptoms  of,  701 

tonsils,  injection  of,  in,  701 

transmission  of,  700 

treatment  of,  705 

vomiting  in,  701 
Influenzal  diseases  of  nose,  349 
Ingested  food,,  decomposition  of,  295 
Inguinal  hernia,  336 
in  pertussis,  676 
Injections,  intramuscular,  120 

intravenous,  120 

subcutaneous,  120 
Injury,  heat,  260,  261,  263 
Insanity,  acute  hallucinatory,  570 
Insensible  perspiration,  23 
Insomnia,  baths  in,  115 

chloral  hydrate  in,  116 

packs  in,  115 

treatment  of,  115 
Inspected  milk,  55 
Inspection  of  school  children,  105 
Instrumental   deliveries,   cerebral  hemor- 
rhage in,  129 

Insufficiency,  cardiac,  413 
Internal  hemorrhagic  pachy meningitis,  457 

hydrocephalus,  acute,  458 

resemblance  to  internal  hemorrhagic 
pachymeningitis,  457 

secretions,  glands  of,  pathology  of,  226 

stimuli  in  producing  skin  diseases,  789 
Intertriginous  eczema,  793 
Intertrigo,  790,  793 
Interventricular  septum,  defect  of,  396 

murmurs  from,  396 
Intestinal  bacteria,  value  of,  12 

canal,  obstruction  of,  329 

catarrh,  chronic,  308 

hemorrhage  in  infantile  scurvy,  187 

polyposis,  321 

stenoses,  congenital,  329 

tract,  emptying  of,  111 

tuberculosis,  320,  720,  721 
diagnosis  of,  311 

in  chronic  pulmonary  tuberculosis,  735 
peritoneal  adhesions  in,  320 
peritonitis,  acute,  in,  321 


Intestinal    tuberculosis,  stenosis   in,    320, 

321 

use  of  rectoscope  in,  321 
treatment  of,  321 
tubercle  bacilli  in,  320 
ulcers,  circular,  in,  320 
Intoxication  (Synonyms;  alimentry  tox- 
icosis, entero-catarrh,  cholera  infantum: 

Indexed    under    Alimentary    intoxica- 

Ifon),  265,  291 

alimentary    (see  Alimentary    intoxica- 
tion), 291 

breast-milk  after  starvation  period  in,  297 

in    cerebral    hemorrhage    of   new-born, 
219 

sugar,  296 

Intracranial  pressure  in  internal  hemor- 
rhagic pachymeningitis,  457 
in  meningococcus  meningitis,  472 
in  serous  meningitis,  475 
Intramuscular   blood-injections   in   treat- 
ment of  anemia,  174 
Intraperitoneal  injection  of  salt  solutions, 

111 
Intraspinal    injections   in    meningococcus 

meningitis,  473,  474 
Intubation  for  obstruction  of  respiration 

in  larynx,  110,  668,  669,  670 
Intubator,  670 
Intussusception,  333 

course  of,  334 

diagnosis  of,  334 

mechanism  of,  333 

symptoms  of,  333 

treatment  of,  335 
Inulin  for  diabetes,  209 
Iodides  in  syphilis,  782 
lodin  secreted  in  milk,  42 

test  in  chronic  dyspepsia,  310 

tincture  of,  care  in  use  of,  on  child's 
delicate  skin,  120 

tonic  action  of,  116 

lodoform,  avoidance  of,  in  treating  sepsis 
of  new-born,   147 

in  tuberculous  meningitis,  465 
Ipecac  in  acute  dyspepsia,  308 
Iridocyclitis  in  meningococcus  meningitis, 

471 
Iritis  in  meningococcus  meningitis,  471 

rheumatic,  712 

syphilitic,  770 
Iron  balance,  negative,  162 

in  milk,  1,  4,  5,  18,  161 

for  premature  children,  125 

medicinal,  in  treatment  of  anemia,  173 

salts  in  fetus,  1 

tonic  action  of,  116 

vegetable,  in  treatment  of  anemia,  172 
Irvine,  Harry  G.:    Diseases  of  the  skin, 

Part  XI,  p.  787 
Ischochymia,  325 

Ischuria  paradoxa  in  spasmophilia,  536 
Isthmus  aortas,  399 
Isodynamia,  20 
Isolation  in  contagious  diseases,  578,  705 


INDEX 


881 


Itch,  Dhobie,  836 
Itching  in  urticaria,  804 
Itch-mite,  791,  816 

v.  JAKSCH-HAYEM  anemia,  168 
course  of,  170 
etiology  of,  170 
occurrence  of,  170 
pronosis  of,  170 
Jactatis  capitis  nocturna,  555 
Jaundice,  acute,  339 
catarrhal,  339 
in  congenital  obstruction  of  bile  ducts, 

341 

in  the  new-born,  151 
Jaw,  growth  of,  30 

Jeans,  Philip  C.:  Syphilis,  Part  X,  p.  750 
Jenner's  discovery,  631 
Joints,  fungus  of,  736 

in  acute  articular  rheumatism,  706 
pyemia  of,  in  sepsis  of  new-born,  146 
tuberculosis  of,  in  scrofula,  735 
Juvenile  heart,  417 

KAOLIN,  114 

Kassowitz '  inflammation,  191 

Rations,  18 

Keratitis  in  meningococcus  meningitis,  471 

in  ophthalmia,  150 

in  syphilis,  777 
Keratodermia  palmaris  et  plantaris,  844 

symmetrical  of  the  extremities,  844 
Keratoma,  congenital,  of  palms  and  soles, 

844 

Keratomalacia,  a  food  disease,  19 
Kernig's  sign  in  meningococcus  meningitis, 

470 

in  tuberculous  meningitis,  460,  463 
Kidney,  abscesses  of,  439 

cloudy  swelling  of,  428 

cystic  degeneration  of,  456 

diseases  in  infants,  436 
chronic,  436 

tabulation  of,  in  infants,  12 
in  new-born,  12 

palpation  of,  79 

purulent  diseases  of,  439 

situation  of,  in  new-born,  13 

size  of,  in  infancy,  12 
in  new-born,  12 

tumors  of,  456 

uric  acid  infarcts  in,  13,  154 

weight  of,  in  new-born,  13 
Kirstein's  method  of  bronchoscopy,  74 
Klumpke's  type  of  paralysis  of  brachial 

plexus,  131 

Koch's  discovery  of  tubercle  bacillus,  720 
Koch- Weeks  bacillus  in  ophthalmia,  150 
"Koepfchen"  bacteria,  12 
Koplik's  spots  in  measles,  348,  601,  602, 

606,  607,  608,  613,  614 
method  of  examining  for,  602 
Kuhn's  mask,  369 
Kyphoscoliosis,  525 
Kyphoses  in  rickets,  201,  203 
56 


LABYRINTH  in  meningococcus  meningitis, 

471 

Lachrymal  secretion,  absent  at  birth,  34 
Lactagol,  40 
Lactalbumin,  4,  5,  7 
Lactase,  293 

action  on  milk-sugar,  10 

in  metabolism,  17 

percentage  of,  in  milk,  4 
Lactation,  chloroform  anesthesia,  effect  of. 
on,   42 

duration  of,  41 

hunger,  effects  of,  on,  42 

in  infants,  14 

maintenance  of,  by  exchanging  babies, 
124 

menses  during,  42 

does  not  prevent,  41 

of  wet-nurse,  duration  of,  41 

premature  child,  difficulty  of  maintain- 
ing, for,  124 

spontaneous  failure  of,  41 
Lactogen,    151 
Lactoglobulins,  4 

Lactophenin,  hemocytolysis  from,  166 
Lactosuria,  208 
Lacunar  angina,  249 

differentiated  from  diphtheria,  656 
La  grippe,  699 
Larosan,  286 

Laryngeal  stenosis,  oxygen  in,  110 
Laryngismus  stridulus,  360 
Laryngitis,  acute,  361 

phlegmonosa,  363 

in  tuberculosis,  735 
Laryngoscopic  examination  of  children,  74 

anesthesia  in,  74 
Laryngospasm,  530,  533 

treatment  of,  540 
Larynx,  diphtheria  of,  649 

papilloma  of,  364 

Lateral  sclerosis,  amyotrophic,  528 
Lavage,  gastric,  112,  113 
in  acute  dyspepsia,  308 
in  dyspepsia,  312 
Laxatives,  112 

saline,  112 
Lead,  poisonous  action  of,  on  the   blood, 

165,  167 

on  bone-marrow,  165 
Leanness,  persistent,  211 

with  stigmata  of  degeneration,  213 
LeBuys,  L.  R.:    General  symptomatology 

and   technic  of   examination,    Chapter 

III,  p.  79 

Lemons  in  infantile  scurvy,  190 
Lenticular  degeneration,  progressive,  524 

nucleus,  progressive  degeneration  of,  528 
Leptomeningitis  of  syphilitic  origin,  476 
Leucemias,  differentiation  from  scrofula, 

731 
from  pseudoleucemia,  731 

group  of,  175 

lymphatic,  176 

myelo-cytomatosis,  179 


832 


INDEX 


Leucemias,  myeloid,  179 
pathogenesis  of,  183 
therapy  of,  183 
Leucemic  lymphadenosis,  176 
Leucocytes,  mononuclear,  origin  of,  156 

Trommsdorf 's  test  for,  56 
Leucocytosis  in  alimentary    intoxication, 

292,  293 

in  blood  of  new-born,  2 
in  milk,  6 
Leucopenia,  168 

polynuclear,  168 
Levulose,  17 
Lichen,  216,  728 
in  scrofula,  73b 
scrofulosorum,  822 
strophulus,  216 
urticatus,  216,  803,  805,  807 
Liebig's  malt  soup  feeding,  in  intestinal 

infections,  319 

Ligamentum  teres,  origin  of,  134 
Ligation  of  cord,  hemorrhage  from,  144 
Light  reflex,  33 
Lip,  syphilis  of,  778,  785 

thickening  of  upper,  in  scrofula,  733 
Lipase,  16 

Lipoid  substances,  hemic  poison,  167 
Liquid  diet  in  acute  dyspepsia,  308 
Lisping,  353  _  , 

Listlessness     in     tuberculous     meningitis, 

459 

Litmus  reaction  of  milk,  4,  5 
Little's  disease,  503,  505,  509,  524 
cerebral  hemorrhage  and,  130 
in  asphyxiated  children,  126 
in  premature  children,  125 
spasticity  of  limbs  in,  503 
etiologic  rule,  500 
Liver,  abscess  of,  from  lymphangitis  of 

umbilical  vein,  141 
carcinoma  of,  340 
cirrhosis  of,  339,  340 
alcoholic,  340 
congenital,  339 
congestive,  340 
icteric,  340 
malarial,  340 
syphilitic,  339 
cysts  of,  340 
diseases  of,  339 
echinococcus  cyst  of,  340 
gummata  of,  340 
in  typhoid  fever,  693 
infantile,  340 

jaundice  in  diseases  of,  339 
palpation  of,  79 
percussion  of,  79 

pericarditic  pseudocirrhosis  of,  412 
pseudocirrhosis  of,  in  Wilson's  disease, 

524 

sarcoma  of,  340 
syphilis  of,  339,  340,  759,  776 
tissues,  hyperacidity  of,  in  alimentary 

intoxication  294 
tumors  of,  340 


Lobar  pneumonia  (see  pneumonia,  lobar). 

OT/?  ' 

376 

Lobster,  causing  urticaria,  804 
Lobulation  of  kidneys  in  new-born  and  in 

infants,  12 
Local  rubella,  620 
Locus  minoris  resistentiae,  101 
Loeffler  's  bacillus,  causative  agent  of  diph- 
theria, 637,  638 

Longitudinal  sinus  for  intravenous  injec- 
tions, 120 

Lordosis  and  orthotic  albuminuria,  426 
Lordotic  dysbasia,  progressive,  525 
Loss  of  water  in  system,  how  prevented, 

110 

Louse,  head,  791 
Lumbar  puncture,  82,  83 

aspiration  of  fluid  by  syringe  danger- 
ous, 82 

diagnostic  value  of,  82 
dry,  84 

in  convulsions,  542 
in  differentiating  cerebral  hemorrhage 

130 
in  internal  hemorrhagic  .pachymenin- 

gitis,  457,  458,  461 

in  meningococcus  meningitis,  472,  473 
in  purulent  meningitis,  466,  467 
in  serous  meningitis,  475,  476 
in  tuberculous  meningitis,  464,  465 
in  tumor,  suspected,  of  the  brain,  82 
in  uremia,  421 
pressure  in,  82 

methods  of  determining,  82 
Lungs,  auscultation  of,  78 
cavity  formation  in,  720,  723 
dulness  over,  77 
examination  of,  77 
tuberculosis  of,  chronic,  735 

primary  lesion  in,  721,  727 
Lupus,  818,  819,  821 
Finsen  rays  in,  821 
treatment  of,  821 
verrucosus,  820 
X-rays  in,  821 
Luxations  at  birth,  132 
Lymph  channels,  tuberculosis  in,  722 
gland  or  node,   bronchial,  enlargement 

of,  78 

cervical,  tuberculous,  730 
enlargement  of,  in  scrofula,  730 
hyperplasia  of,  in  exudative  diathesis, 

215,  217,  219 

in  lymphatic  leucemia,  176,  178 
mesenteric,  tuberculous,  730 
pharyngeal,  tuberculous,  730 
sublingual,  tuberculous,  730 
syphilitic,  771 
tubercular,  721,  722 
tonsillar,  tuberculous,  730 
Lymphadenitis,  retropharyngeal,  252 
Lymphadenosis,  aleucemic,  178 

leucemic,  176 

Lymphangitis  of  umbilical  vein,  140 
hepatitis  from  141 


INDEX 


883 


Lymphangitis  of  umbilical  vein,  icterus 

from,  141 

peritonitis  from,  141 
Lymphatic  children,  fever  treatment  in, 

108 

conjunctivitis,  731 
diathesis,  213 
leucemia,  176 

acute  course  of,  177 
blood  findings  in,  178 
course  of,  177 
diagnosis  of,  177 
errors  of  diagnosis  in,  178 
liver,  enlargement  of,  in,  178 
lymph  nodes  in,  176 
onset  of,  177 
Rieder's  cells  in,  177, 178 
spleen,  enlargement  of,  in,  178 
symptoms  of,  177 
tonsils,  hyperplasia  of,  in,  178 
thymus  enlargement  of,  in,  178 
X-rays  of,  178 
organs  in  obesity,  211 
parenchyma,  156 
ring,  248 

system  in  scrofula,  730 
Lymphatism,  730,  731 
Lymphocytes  in  blood  of  new-born,  2 

of  children,  2 
in  milk,  6 

in  spinal  fluid  in  serous  meningitis,  475 
Lymphocytomatoses,    176 
Lymphosarcoma  of  tonsil,  252 
Lymphosarcomatosis,  178 
'blood  in,  179 

hemorrhagic  diathesis  in,  179 
of  mediastinum,  178 
resemblance  to  malignant  tumors,  178 
thymus,  involved  in,  179 
treatment  of,  183,  184 

MACULA  lutea  in  amaurotic  familial  idiocy, 

523 

Magnesium  salt  in  treatment  of  tetanus, 
143 

sulphate  in  erysipelas,  149 
Maladie  des  tics  conrulsifs,  556 
Malaise  in  acute  dyspepsia,  307 
Malaria,  endogenous  hemplytic  poison,  166 
Malformations,      congenital,      increasing 

death-rate,  95 
Malingering,  102 
Malt  extract  in  infant  feeding,  61 

soup,  preparation  of,  268 

sugar  in  infant  feeding,  61 

tropon,  40 
Mai  thus  theory  as  to  high  mortality  of 

children,  89 
Maltose,  17 

in  acute  dyspepsia,  290 

in  infant  feeding,  61 
Mammary  gland,  functioning  of,  at  birth, 

14 

galactagogue  of  hormone  type  desired 
for  action  on,  41 


Mammary  gland,  hormone  for  increasing 

milk  of,  41 

involved  in  mumps,  687 
relation  to  placenta,  41 

to  productive  organs,  40 
Mania,  570 
Manometer  for  determining  pressure  of 

spinal  fluid,  82 
Marie 's  disease,  525 
Marriage  of  close  relatives,  98 
Massage  in  fissure  of  the  nipples,  38 

in  scoliosis,  102 
Masses  jaunes,  151 

Mastication,  first  appearance  of,  in  child,  7 
Mastitis,    causing   hypertrophy   of   other 
breast,  47 

emptying  of  breast  in,  38 

from  fissure  of  the  nipples,  38 

hyperemia  for,  38 

ice-bags  for,  38 

incisions  in,  38 

milk  in,  not  dangerous  to  child,  147 

moist  applications  for,  38 

of  new-born,  151 

treatment  of,  151 

treatment  of,  38 
Mastoiditis,   358 
Masturbation,  454,  562 

action  on  heart,  418 

frequency  of,  454 

neurasthenia  and,  559,  561 
Maternal  mortality  rate  unusually   high 

in  the  United  States,  92 
Measuring  tape  of  von  Pirquet,  28 
Meat  broth  in  acute  dyspepsia,  290 

juice  in  treatment  of  anemia,  173 
Meckel's  diverticulum,    135 
Meconium,  11 

in  air  passages  of  asphyxiated  child,  126 

in  middle  ear,  356 
Median  paralyses,  528 
Mediastinal  nodes,  caseated,  458 
Mediastinum,  lymphosarcomatosis  of,  178 
Medulla  at  birth,  31 
Medullated  tracts  at  birth,  31 
Measles  (morbilli),  598 

afebrile,  608 

allergy  in,  722 

blepharitis  in,  609 

blood  in,  606 

bronchitis  in,  610 

broncho-pneumonia  in,  374,  610,  615 

carriers  of,  598 

causative  organism  unknown  in,  598 

combined  with  chicken-pox,  577 
with  diphtheria,  576,  612 
with  pertussis,  610 
with  scarlet  fever,  576 
with  tuberculosis,  613,  735 

complications  of,  607 

conjunctivas  in,  601,  605,  609 

convalescence  in,  607 

coryza  in,  601 

cough  in,  601,  603,  606 

course  of,  607 


884 


INDEX 


Measles,  definition  of,  598 
diagnosis  of,  613 
diazo-reaction  in,  606 
diphtheria  complicating,  612,  640 
disease- picture  of,  600 
eczema  during,  609 
epistaxis  in,  605 
exanthema  in,  602,  603,  608,  609 

bath  in  delayed,  615 
eyes  in,  601,609 
Faroe  Islands  statistics  of,  599 
florid  stage  of,  603 
German,  616 
"going  in"  of,  608 
hemorrhages  in,  185 
incubation  period  of,  599,  600 
kidneys  in,  606 
Koptik's  spots  in,  601,  602,  606,  607  608, 

613,  614 

method  of  examining  for  602 
laryngitis  in,  609 
mortality  of,  from,  600 
in  Bavaria,  572 
in,  Prussia,  571 
mouth,  exanthem  in,  602,  609 
mucous  membrane  of  mouth  in,  601 
noma  in,  609 
nose  lesions  in,  348 
pathologic  findings,  in,  600 
pleurisy  in,  610 
pneumonia  in,  608,  610,  615 

contagiousness  of,  in,  610 
prodromes  of,  598,  600,  601,  613 
prognosis  of,  614 
prophylaxis  of,  614 
pseudocroup  in,  601 
recrudescence  of,  609 
rhinitis  in,  601,  605,  609 
rubella  and,  613 
second  attack  of,  rare,  599 
serous  meningitis  from,  474 
stages  of,  600 
stools  in,  606 
symptoms  of,  600 
temperature  in,  601,  605 
tonsils  in,  601 
toxic  form  of,  607 
treatment  of,  615 
tuberculin  reaction  lacking  in  eruption 

of,  613 
vulva  in,  609 

Megalerythema  epidemicum,  620 
Melancholia,  570 
Melena  neonatorum,  148 

central  nervous  irritation  causing,  148 

citrated  blood  for,  149 

coagulation  time,  prolonged  in,  149 

bleeding  time,  prolonged  in,  149 

diagnosis  of,  149 

duodenal  ulcers  in,  148 

epinephrin  for,  149 

etiology  of,  148 

gastric  hemorrhage  from,  149 
ulcers  in,  148 

gastro-intestinal  tract,  source  of,  148 


Melena  neonatorum,  gelatin  for,  149 

ice  in  treatment  of,  149 

iron  in  treatment  of,  149 

mother's  blood  for,  149 

salt  solution  for,  149 

septic,  148 

septo-hemorrhagic,  148 

serum  for,  149 

spuria,  148 

symptomatic,  149 

syphilis  causing,  148 

thrombosis  of  intestinal  vessels  caus- 
ing, 148 

treatment  of,  149 

true,  148,  149 

vera,  148 

whole  blood  in  treatment  of,  149 
Melituria,  208,  209 
Membrano-ulcerative  angina,  251 

organisms  causing,  251 

salvarsan  for,  252 

transmissibility  of,  251 

treatment  of,  252 
Membranous,  bronchitis,  637 
croup,  637 
enteritis,  3ll 

Meningeal  irritation  in  alimentary  intox- 
ication, 292 
tuberculosis,   728 
Meninges,  diseases  of  the,  457 

distension  by  oxygen  in  meningococcus 

meningitis,  474 
in  serous  meningitis,  474 
Meningism,  476 
Meningitis,  basilar,  458 

basilaris  posterior  in  meningococcus  men- 
ingitis, 472 

cerebro-spinalis  siderans,  471 
meningococcic  (see  below),  467 

hemorrhages  in,  185 
syphilitic,  465,  476 
tuberculous,  458,  729,  726 

recovery  from,  729 
Meningococcus  meningitis,  467 

abortive  forms  of,  471 

abscesses  in,  471 

acetphenetidin  in,  473 

albuminuria  in,  469 

analeptics  in,  473 

angina,  retronasal,  in  467 

antimeningococcic  serum  treatment  of, 
473 

antipyrin  in,  473 

apical  pneumonia  in,  472 

appetite  impaired  in,  469 

arc  de  cercle  in,  469 

atropin  for  vomiting  in,  473 

backache  in,  468 

blindness  in,  471,  473 

blood  in,  469 

brain  membranes  in,  467 

breast-milk  for  infants  in,  473 

Brudzinski  's  neck  sign  in,  470 

cachexia  in,  469 

camphor  in,  473 


INDEX 


885 


Meningococcus  meningitis,  carriers  in,  467 
chills  in,  468 
clonic  spasms  in,  469 
complications  of,  471 
consciousness  in,  468,  469,  472 
convalescence  in,  468 
convulsions  in,  469,  470 
course  of,  471 
deafness  from,  473 
death  from,  472 
decubitus  in,  473 
delirium  in,  469 
dermatographia  in,  470 
development  of,  467 
diagnosis  of,  472 
diet  in,  473 

dimethylamino-antipyrin  in,  473 
diplococcus   intracellularis,   causative 

agent  of,  467,  473 
duration  of,  471,  472 
electrical  reactions  in,  472 
empyema,  pleural,  in,  471 
endocarditis  in,  471 
epidemiology  of,  467 
etiology  of,  467 

exudate,  disappearance  of,  in,  468 
eye  complications  in,  468,  471 

muscles,  paralysis  of,  in,  470 
feeding-tube  in,  473 
fibrin,  formation  of,  in  spinal  fluid,  471 
fontanelles  in,  470,  472 

ventricular,  puncture  through,in,  474 
fulminant  forms  of,  471 
gastro-intestinal  disturbances,  differ- 
entiation from,  472 
Gram-negative    diplococci    in    spinal 

fluid,  468  470,  473, 
headache  in,  468,  472 
herpes,  labial,  in,  468,  469,  472 
hexamethylenamine  in,  473 
hot  baths  in,  473 
hydrocephalus  in,  471,  472,  473 
hyperesthesia  in,  472 
ice  applications  in,  473 
idiocy  following,  471,  473 
inequality  of  pupils  in,  470 
infection  in,  467 

influenza,  differentiation  from,  472 
injections  in,  473,  474 
intracranial  pressure  in,  472 
intraspinal  injections  in,  473,  474 
intravenous  injections  in,  473,  474 
iridocyclitis  in,  471 
iritis  in,  471 
keratitis  in,  471 
Kernig's  sign  in,  470 
labial  herpes  in,  468,  469,  472 
labyrinth  in,  471 
lumbar  puncture  in,  472,  473 
membranes  of  brain  in,  467 
meningitis    basilaris    posterior    form 

of,  472 
meningitis    cerbro-spinalis     siderans 

form  of,  471 
meningococci  in,  471 


Meningococcus  meningitis,  mental  retard- 
ation from,  471 

morphin  in,  473 

mortality  in,  472 

nasopharynx  in,  467 

neck,  rigidity  of,  in,  468,  469,  472 

nephritis  in,  469 

nervous  symptoms  in,  469 

Nonne  test  in,  473 

opisthotonos  in,  469 

optic  atrophy  in,  471 

otitis  media  in,  471 

panophthalmia  in,  471 

pathogenesis  of,  467 

pathological  anatomy  of,  468 

pericarditis  in,  471 

pharyngeal  tonsil  in,  468 

pharyngitis  in,  467 

physiologic  salt  solution  in,  474 

pia  in,  468 

pleural  empyema  in,  471 

polymorphonuclear  leucocytes  in,  470 

polyvalent  antimeningococcic  serum 
in  treatment  of,  473 

psychic  symptoms  in,  471 

prognosis  of,  472 

prophylaxis  of,  473 

protein  increased  in,  470 

pulse  in,  469 

rash  in,  469 

recovery  in,  472 

reflexes  in,  470 

retronasal  angina  in,  467 

respirations  in,  469 

rest  in,  473 

rheumatoid  swelling  in,  471 

rigidity  of  neck  in,  468,  469,  472 

salt  solution  in,  474 

scaphoid  abdomen  in,  469 

sense  organs,  complications  of,  in,  471 

sensitiveness  in,  469 

sequela?  of,  471 

serum  therapy  of,  472,  473 

skin  in,  469 

sopor  in,  469 

spasmophilia,  differentiation  from,  472 

spinal  fluid  in,  470 

spleen  in,  469 

sporadic  cases  of,  467 

spread  of,  467 

status  lymphaticus  in,  467 

stomach-tube  feeding  in,  473 

strabismus  in,  470 

symptoms,  special,  in,  468 

temperature  in,  468,  469,  472 

termination  of,  471 

tonic  spasms  in,  469 

transmission  of,  473 

treatment  of,  473 

tremor  in,  472 

Trommer's  test  in,  470 

typhoid  fever,  differentiation  from. 
472 

urine  in,  469 

ventricles  in,  468 


886 


INDEX 


Meningococcus     meningitis,     ventricular 

puncture  in,  474 
vomiting  in,  468,  469,  473 
Meningo-encephalitis,  tuberculous,  459 
Menses,  absence  of,  in  lactating  woman,  42 
appearance  of,  in  lactating  woman,  42 
effect  of,  on  lactation,  43 
Mental  debility,  567,  569 
development  and  size  of  brain,  28 
retardation  from  meningococcus  menin- 
gitis, 471 

Menu,  child's  51,  65 
Mercurial  inunction  in  purulent  meningitis 

467 

in  serous  meningitis,  476 
in  syphilis,  783 
in  tuberculous  meningitis,  465 
Mercuric  chloride  in  erysipelas,  149 
Mercury  in  syphilis,  782,  783 
inunctions  of,  783 
poisonous  action  on  blood,  167 
secreted  in  milk,  42 
M6rys  vegetable  bouillon,  297 
Mesentery,  thrombosis  of,  in  chlorosis,   164 
Metabolism,  accessory  food  substances  in, 

19 

carbohydrates  in,  17 
convulsions,  caused  by  disturbances  of, 

34 

diseases  of.  Part  II,  p.  156  ] 
excessive,  in  children,  22 
gaseous,  23 
in  spasmophilia,  533 
inorganic,  18 
lactose  in,  17 

mineral  constituents  in,  18 
organic,  18 
pathology  of,  15 
physiology  of,  15 
reduced,  211 
soap  formation  in,  17 
total,  19 
water  in,  18 
Methemoglobinuria,  166 

paroxysmal,  166 
Meyer,    K.    F.;    The    acute    infectious 

diseases,  Part  VIII,  p.  571 
Meyer,  L.  F.:    Diseases  of  the  digestive 

system,  Part  III,  p.  242 
Diseases  of  the  new-born,  121 
Microcephaly,  484 

closure  of  anterior  fontanelle  in,  28 
Micromelia  chondromalacia,  236 
Micturition,  frequency  of,  in  children,  13 
Middle  ear,  amniotic  fluid  in,  356 
diseases  of,  355 
in  purulent  meningitis,  465 
meconium  in,  356 
mucous  fluid  in,  at  birth,  32 
Migraine,  556 
Miliaria,  839 
rubra,  839 
Miliary  tuberculosis,  728 

clinical  recognition  of,  729 
X-rays  in,  729 


Milium,  840 
Milk,  256 

alcohol  in,  42 

amount  given  end  of  first  year,  52 

amphoteric  reaction  of,  4,  5 

ash  of,  4,  5 

mineral  constituents  of,  5 

asses',  4 

bacteria,  260 

boiling  of,  changes  induced  by,  7 

killing  ferments  and  immune  bodies 

preferred  to  pasteurization,  57 
bottle,  covering  for,  57 

time  to  stop  giving,  52 
bromine  secreted  in,  42 
calcium  salts  in,  4,  5 
calories  in,  4,  62,  193 
certified,  55 

dispensing  of,  104 
chlorine  in,  4,  5 

choice  of,  for  infant  feeding,  55,  56 
"coming-in"  of,  49 
composition  of,  258 
condensed,  in  infant  feeding,  62 
contaminated,  55,  260 
cow's,  256 

composition  and  peculiarities  of,  4 

giving  positive  tuberculin  test,  55 

per  pound  of  body-weight,  64 
curdling  of,  56 
curds,  273,  274 
decomposition  of,  55 

exogenous,  in  alimentary  intoxication, 

294 

deficiency  of  iron  salts  in,  1,  4,  5,  18,  161 
digestibility  of,  4 
dilutions,  58 

changes  induced  by,  7 
dispensing  of  pure,  104 
diseased  animals  supplying,  55 
fats,  5 

percentage  of,  4,  5 
ferments  in,  6,  7 
ferment-like  substances  in,  257 
for  infants,  55 
free  fatty  acids  of,  5 
glycerin  esters  of,  5 
goat's,  advantages  of,  56 

composition  and  peculiarities  of,  4 
heat  value  of,  4 
human,    composition   and   peculiarities 

of,  4 

immune  bodies  in,  6,  7 
in  mastitis,  not  dangerous  to  child,  147 
in  puerperal  fever,  to  be  given  child,  147 
inspected,  55 
inspection  of,  104,  260 
iodin  secreted  in,  42 
iron  in,  1,  4,  5, 18,  161 
leucocytes  in,  6 
lymphocytes  in,  6 
menses,  effect  of,  on,  43 
mercury  secreted  in,  42 
mineral  constituents  of,  18 


INDEX 


887 


Milk,  mixed  diet,  64 
mother 's,  expressed,  39 

pumped,  39 

of  magnesia,  laxative  action  of,  112 
organisms  in,  source  of,  55 
pap,  52 

pasteurization  of,  6,  56 
advantages  of,  57 
changes  induced  by,  6 
phosphorus  in,  4 
proper  care  of,  55 
quantity  of,  secreted  in  24  hours,  47 

taken  at  each  feeding,  47 
rash,  798 

raw,  dangers  from,  56,  57 
reaction  of,  4,  5 
salicylic  acid  secreted  in,  42 
sanitary,  55 
"shooting-in,"  of,  45 
souring  of,  5,  6 
split-up  by  lactase,  10 
sterilized,  6 

advantages  of,  57 
changes  induced  by,  6 
sugar,  5 

amount  in  various  kinds  of  milk,  5 
changed  to  caramel  by  boiling,  7 
disaccharide,  17 
end  products  of,  17 
in  colostrum,  6 
in  metabolism,  17 
lactose  action  on,  10 
teeth,  care  of,  67 

incisors  first  to  appear,  30 
loss  of,  order  of,  30 
tolerance  to,  257 
total  nitrogen  of,  4 
toxins,  260 

volatile  fatty  acids  of,  5 
"witch's,"  14,  151 
whole,  calories  of,  62 
Milking  of  breasts,  methods  of,  124 
Mimicry,  facial,  33 
Mineral  constituents  of  flour,  61 

of  milk,  18 

metabolism  in  rickets,  193 

waters,  ferruginous,  173 

Mitral  insufficiency,  405,  406 

stenosis,  405 

Mixed  diet  in  intestinal  infections,  319 
less  milk  required  in,  64 
transition  to,  65 
feeding,  49,  50,  306 
weaning  and,  49,  50 
wet-nurse  and,  53 
Moist  compresses,  107 
packs,  107 
sheet,  107 

Molar,  six-year,  eruption  of,  30 
Mole,  pigmented,  849 
Molluscum  contagiosum,  848 

sebaceum,  848 

Mongolism-mongoloid  idiocy,  238 
Monilia  Candida  in  thrush,  247 
Mononuclear  leucocytes,  156 


Mononuclear  leucocytes  in  spinal  fluid  of 

tuberculous  meningitis,  464 
Monoplegia  in  tuberculous  meningitis,  463 
Monosaccharides,  17,  209 
Monothermia  of  the  new-born,  15,  262 
Morbidity  and  mortality,  Chapter  IV,  p.  86 
infant,  103 

of  kindergarten  age,  96 
of  puberty,  96 
of  run-about-age,  96 
of  school  age,  96 
stay-at-home  age,  96 
statistics,  Chapter  IV,  p.  86 
Morbilli,  598 
Morbus  coeruleus,  394,  395 

Werlhofi,  184 
Moro,  Ernst:  Diseases  of  the  skin,  Part  XI, 

p.  787 

Syphilis,  Part  X,  p.  750 
Moro's  carrot  soup,  297 

percutaneous  test  for  tuberculosis,  741 
Morphin  secreted  in  milk  of  animals,  42 
sulphate,  dangers  of,  115 
narcotic  action  of,  115 
Mortality  and  morbidity,  Chapter  IV,  p.  86 
higher  in  summer  months,  89 
infant,   103 

of  large  cities  of  the  United  States  91, 
rate,  maternal,  high  in  United  States,  92 
statistics,  Chapter  IV,  p.  86 
Moser's  serum  in  scarlet  fever,  597 
Mother,  ability  to  nurse,  39 
beneficial  effect  from  nursing  child,  37 
diseases  in,  preventing  nursing  of  child, 

37 

economic  assistance  to,  104 
nursing,  hygiene  of,  41 
nutrition  of,  as  affecting  child,  98 
syphilitic,  may  nurse  own  child,  124 
Mother's  mark,  851 
milk,  300 

calcium  contents  of,  193 
dangerous  substitutes  for,  103 
deficient  in  iron  salts,  1,4,  5,  18,  161 
expressed,  39 
natural  food  of  child,  36 
pumped,  39 

wet-nursing  as  substitute  for,  52 
Motions,  automatic,  of  new-born,  33 
reflex,  of  new-born,  33 
subcortical,  33 

Motor  functions,  delay  in  coordinated,  33 
irritability    in    tuberculous    meningitis, 

465 
Mouth  breathing,  347,  353 

cleansing,  dangers  of,  in  new-born,  66, 

145,  147,  247 
diseases  of,  242 
gag,  74 

traumatic  injuries  to,  242 
tuberculosis  of,  722,  729 
washing,  abuse  of,  in  new-born,  66,  145, 

147,  247 

Muco-sanguineous  evacuations  in  follicular 
enteritis,  315 


INDEX 


Mucous  colitis,  310 

constipation  in,  310 
in  chronic  dyspepsia,  310 
fluid  in  middle  ear  at  birth,  32 
membranes  in  scrofula,  731,  733 

in  tuberculosis  of,  721,  728 
Multiple  erythema,  809 
Mummification  of  umbilical  cord,  134,  135 
Mumps,  684 

atypical  localization  of,  687 
causative  agent  not  known,  684 
clinical  picture  of,  684 
complications  of,  687 
definition  of,  684 
diagnosis  of,  687 
immunity  in,  684 
incubation  period  of,  684 
mammary  gland  involved  in,  687 
meningitis  in,  687 
nephritis  in,  687 
ovaries  in,  687 
pancreatitis  in,  687 
parotid  gland  in,  684 
pathological  anatomy  of,  684 
predisposition  to,  684 
prognosis  of,  688 
testes  infected  in,  687 
transmission  of,  684 
treatment  of,  688 
Murmurs  of  heart,  391 

accidental,  391,  392 
atonic,  392 
mitral  391 
systolic,  391,  392 
tricuspid,  391 
venous,  393 

Muscles,  diseases  of,  529 
Muscular  atrophies,  526 

infantile  progressive  spinal,  526 
atrophy,    perineal   type   of   progressive 

neurotic,  526 
defects,  congenital,  488 
dystrophy,  progressive,  527 
hypertonia,    general,   without    spasmo- 

philia,  543 
hypertonicity  in  alimentary  intoxication, 

293 

Mushrooms,  ectogenous  blood  poison,  166 
Music,  love  of,    in    mongolism-mongoloid 

idiocy,  240 
Mustard  bath,  108 

dangers  of,  in  bronchitis,  108 
in  alimentary  intoxication,  297 
method  of  preparing,  372 
pack,  dangers  of,  in  lymphatic  children, 

108 

in  eczema,  widespread,  108 
Myasthenia  pseudoparalytica,  529 
Myatonia,  489 
diagnosis  of ,  489 
of  Hochsinger,  543 
Oppenheim's  congenital,   mistaken  for 

rickets,  204 
treatment  of,  489 
Myelin  sheaths,  development  of,  31 


Myelitis,  521 

Myelo-cytpmatosis,  179,  183 
arsenic  in,  183 
blood  in,  180 
benzol  in,  183 
diagnosis  of,  180 
differentiation  from  v.  Jaksch's  anemia. 

181 

symptoms  of,  180 
therapy  of,  183 
X-rays  in,  183 

Myelogenous  infantile  osteotabes,  186 
Myeloid  leucemia,  179 
pseudoleucemia,  181,  183 
tissue,  157 

Myelopathic  anemia,  165 
Myelosarcomatosis,  not  occuring  in  child- 
hood, 181 

Myelosis,  treatment  of,  184 
Myelotic  parenchyma,  156 
Myocarditis,  acute,  413 
chronic,  413 
diagnosis  of,  415 
diphtheritic,  414 
rheumatic,  414 
symptoms  of,  413 
treatment  of,  415 
typhoid,  414 

Myopathy  in  rickets,  192,  201 
Myopia,  a  school  disease,  105 
Myoplegia  periodica,  529 
Myositis  ossificans,  progressive,  529 
Myostatic  system,  diseases  of,  524 
Myxedema,   (see  also  hypothyreosis),  226, 

227 
acquired  infantile,  231 

dentition,  disturbances  of,  in,  238 
dwarfism  in,  233 
sporadic  origin  of,  232 
X-ray  picture  of,  233 
causing  obesity,  210 

congenital,  (see  also  hypothyreosis),  226, 
231 

anemia  in,  161 
mistaken  for  rickets,  204 
of  Ord,  228 

NAILS,  ring  worm  of,  837 

Naphthalin  ointment  in  fissured  nipple,  38 

Narcotics,  115 

in  alimentary  intoxication,  297 

in  purulent  meningitis,  467 
Nasal  breathing,  obstruction  to,  110 
Nasopharynx  in  meningococcus  meningitis 

467 

Natural  food  of  infant,  36 
Nausea  in  acute  dyspepsia,  289,  307 
Navel,  amnion,  134 

cutical,  134 

skin,  134 
Neck,  examination  of,  72 

rigidity  of,  in  meningococcus  meningitis 

468,  469,  472 
in  tuberculous  meningitis,  460 

spasms  of,  in  serous  meningitis,  475 


INDEX 


889 


Negative  pressure  in  suckling,  8 

Nelaton  catheter  applied  to  rectal  syringe, 

111 
Neoplasmata,  degenerative,  848 

syphilitic,  774 

Neosalvarsan  in  syphilis,  783 
Nephritis,   absence  of,   in  edema  neona- 

torum,  153 
acute  glomerular,  431 
course  of,  431 
etiology  of,  431 
functional  disturbances  in,  431 
pathology  of,  431 
prognosis  of,  433 
scarlatinal,  433 
symptoms  of,  431 
treatment  of,  433 
chronic,  436,  437 
in  congenital  syphilis,  438 
in  scarlet  fever,  588,  592,  593 
Nephropathy,    acute    diffuse    glomerular, 

431 

glomerulo-tubular,  434 
tubular,  428 
Nephrosis,  428 

chronic,  anemia  in,  167 
pseudo-anemia,  in,  175 
Nervous  anorexia,  328 

gastro-intestinal  diseases,  322 
system,  compared  with  body-weight,  31 
diseases  of,  Part  IX,  p.  457 
endogenous  diseases  of,  522 

pathologic  anatomy  of,  522 
prognosis  of,  522 
prophylaxis  of,  523 
treatment  of,  523 
examination  of,  81 
functional  diseases  of,  530 
heredito-degenerative  diseases  of,  522 
familial  diseases  of,  522 

pathologic  anatomy  of,  522 
prophylaxis  of,  523 
prognosis  of,  522 
treatment  of,  523 
of  infant,  31 
of  new-born,  31 
organic  diseases  of,  457 
peripheral,  diseases  of,  528 
syphilis  of,  759,  760,  769 
vomiting,  327 
Neuralgia,  529 
occipital,  529 
trifacial,  529 
Neurasthenia,  559 

masturbation  and,  559,  561 
treatment  of,  561 
Neurofibromatosis,  general,  528 
Neuropathic  children,  care  of,  102 
constitution,  553 
diathesis,  213 

women,  suggestive  treatment  for,  37 
Neuropathy,  hereditary,  553 
Nevus,  849 
flammeus,  851 
pigmented,  849 


Nevus  pigmentosus,  849 

carbon  dioxide  snow  for,  851 

freezing  of,  851 

radium  treatment  of,  851 

treatment  of,  851 

X-ray  treatment  of,  851 
sanguineus,  851 
vascular,  849 
vasculosus,  851 

New-born,  albuminuria  of,  12,  154 
American  weight  of,  24 
basophilic  leucocytes  in,  2 
bathing  of,  66 
blood-cells  in,  2 
body  weight  and  surface,  relations  of,  14, 

20 

cells  in  blood  of,  2 
cephalhematoma  of,  127,  128,  129 
cerebral  hemorrhage  in,  126,  129 
dangers  to,  from  artificial  feeding,  58 
definition  of  a  healthy,  36 
departures  from  adult  life,  1 
differences  from  adult,  1 
diseases  of,  Part  I,  p.  121 
edema  of,  153 

eosinophilic  leucocytes  in,  2,  158 
erysipelas  of,  149 
evacuations,  first,  11 
factors  affecting  weight,  24 
fat  variations  in  food  of,  16 
feeding  of,  43 
first  feeding  of,  43 

motions  of,  33 

four-hour  feeding  of,  46 
heart,  description  of,  in,  1 
hemoglobin,  percentage  of,  in,  158 
hemorrhagic  disease  of,  126 

idiopathic,  144 
intervals  between  feeding,  46 
kidneys  of,  13 
leucocytosis  in,  2 
loss  of  weight  in,  24 
lymphocytes  in  blood  of,  2 
mammary  gland,  swelling  of,  in,  151,  158 
mastitis  in,  151 
mineral  constituents  of,  18 
mononuclear,  large,  cells  in,  158 
monothermia  of,  15 
nervous  system  of,  31 
number  of  feedings  from  the  breast,  46 
ophthalmia  of,  150 
paralysis  of,  131 
percentage  of  hemoglobin  in,  2 
polymorphonuclear  neutrophiles  in  blood 

of,  2,  158 

proteinuria  of,  154 
ptyalin  in  saliva,  8 
quantity  of  milk  suckled,  47 
red  cells  per  cubic  millimeter  in,  158 
respiratory  apparatus  in,  2 
saccharin  in  first  feeding  of,  43,  49 
scleredema  of,  153 
sepsis  of,  144 
septic  icterus  of,  153 
skin  of,  characteristics  of,  13 


890 


INDEX 


New-born,  sleep  following  birth,  43 

specific  gravity  of  blood  in,  2 

tendon  reflexes  of,  34 

tetanus  of,  142 

from  umbilical  wound,  98 

transitional  cells  in,  2 

uric  acid  infarcts  of,  13,  154 

vaginal  hemorrhage  of,  154 

water  contents  of,  1 

weight  of,  factors  affecting,  24 
of  heart  in,  1 
to  determine  number  of  feedings,  47 

white  cells  per  cubic  millimeter  in,  158 
Nightmare,  558 
Nipples,  cleansing  of,  42 

eczema  of,  treated  by  ichthyol,  46 
by  silver  nitrate,  46 

fissured,  38 
massage  in,  38 
treatment  of,  38 

for  nursing  bottle,  57 

retracted,  preventing  nursing,  38 

rubber  cap  for,  57 

shields,  dangers  of,  44 

use  of,  38 
Nitrogen  in  physiology  of  metabolism,  15 

in  protein,  15 

metabolism,  end  products  of,  16 

retention  of  infant,  16 

total,  of  milk,  4 
Nits,  treatment  of,  816 
Nodding  epilepsy,  545 
Nodes  in  scrofula,  730,  731 
Noeggerath,  C:    Diseases  of  the  genito- 
urinary system,  Part  VI,  p.  419 
Noise  heard  at  three  months,  32 
Noma,  245,  246 

diphtheritic,  246 

etiology  of,  246 

of  vulva  in  measles,  609 

secondary  to  other  infections,  246 

surgical  interference  of,  246 

treatment  of,  246 
Non-granular  parenchyma,  156 
Non-spa  smophilic  eclampsia,  541 
Nonne  test  in  meningococcus  meningitis, 

473 
Normal  health,  262 

infant,  care  and  feeding  of,  Chapter  II, 
p.  36 

nutrition,  262 

Normality,  understanding  of,  36 
Nose  bleed  (epistaxis),  354 

development  of,  347 

diphtheria  of,  348 

diseases  of,  347 

foreign  bodies  in,  354 

influenza!  diseases  of,  349 

gonococcic  infection  of,  349 

measles  of,  348 

meningitis,  epidemic,  of,  349 

poliomyelitis,  acute,  of,  349 

polyps  of,  353,  354 

primary  focus  of  epidemic  meningitis,  349 
of  variola,  348 


Nose  saddle-form,  237,  239 
sanguine-purulent  discharge  from,  348 
scarlatina  of,  348,  349 
scrofula  of,  731,  733 
syphilis  of,  349,  352 
tuberculosis  of,  349,  352 
primary,  721 
secondary,  722 
variola  of,  348 

Nuclear  atrophy,  infantile,  488 
Nucleus,  absence  of,  488 

congenital  aplasia  of,  488 
Nurseries,  day,  104 

fresh  air  for,  67 
Nursery  pen,  68 
Nursing  bottle,  nipple  for,  57 

coverings  for,  57 
by  one  or  both  breasts,  45 ' 
conception,  prevented  by,  43 
first  attempt  at,  44 
in  lying-in  hospitals,  39 
in  private  practice,  40 
mother,  39 
diet  of,  41 

diseases  in,  preventing,  37 
hygiene  of,  41 
menses  during  period  of,  42 
not  prevented  by  syphilis,  39 
prevented  by  cleft  palate,  39 
Nutant  spasms,  543 
Nutrition  affecting  child,  98 
infection  and,  299 
normal,  262 
obstacles  to,  36 

overcoming  of,  to,  41,  42,  43 
of  twins,  47 
physiology  of,  3 
Nutritional  diseases,  256 
causing  death,  94 
classification  of,  264 
due  to  food. 264 
to  congenital  constitutional  defects, 

264 

to  infection,  264 
ex  correlatione,  258 
general  symptomatology  of,  262 
in  breast-fed  infants,  303 
diagnosis  of,  304 
etiology  of,  303 
treatment  of,  304 
in  infants,  255 
in  older  children,  307 
with  toxic  manifestations.  265,  289 
without  toxic  manifestation,  264 
with  diarrhoea,  264 
without  diarrhoea,  264 
Nystagnus  in  tuberculous  meningitis,  462 

OATMEAL  diet  in  diabetics,  209 

in  infant  feeding,  61,  63 
Obedience  in  child,  69 
Obesity,  210 

alcoholism  causing,  210 

alimentary,  210 

athyroideal  type  of,  210 


INDEX 


891 


Obesity,  castration  causing,  210 
ectogenous,  210 
endogenous,  210 
etiology  of,  210 
exercise,  lack  of,  causing,  210 
hypo-athyroideal  type  of,  210 
hypophysical  injury  causing,  475 
in    hereditary  ataxia  of  Werdnig-Hoff- 

mann,  210 

infantilism,  genital,  causing,  210 
myxedema  causing,  210 
overeating,  causing,  210 
Obstacles  to  nursing,  overcoming  of,  43 
Obstetrician  hand  in  spasmophilia,  536 
Obstipation,  331     • 
gray,    265 

in  tuberculous  meningitis,  459,  463 
treatment  of,  118 
O'Dwyer's  tubes,  669 
Oil  in  treatment  of  chronic  dyspepsia,  313 
Oligochromemia,  159,  163,  164 
Oligosideremia,  161 
Omphalomesenteric  duct,   persistence  of, 

135,  139 

Omphalitis  of  umbilical  stump,  135,  139 
prognosis  of,  140 
treatment  of,  140 
Onychomycosis,  837 
Open-air  schools  for  tuberculous  children, 

105 

Ophthalmia  neonatorum,  150 
antiseptic  solutions  in,  150 
argyrol  in,  151 
articular  metastases  in,  151 
Bier's  hyperemia  for  joint  affections 

in,  151 

blindness  from,  150 
boric  acid  in,  150 
chlamydozoa  in,  150 
cold  in  treatment  of,  150 
cornea,  injury  to,  in,  150,  151 
Crede's  prophylactic  method  in,  150 
dermal  abscesses  from,  150 
duration  of,  150 
etiology  of,  150 
exanthemata  from,  150 
eyes,  washing  of,  in,  150 
Giemsa  method  of  staining  in,  150 
gonococcus  in,  150 
gonorrhea!  arthritis  from,  150 

synovitis  from,  150 
heat  in  treatment  of,  150 
ice  in  treatment  of,  150 
inclusion  bodies  in,  150 
joint  affections  in,  151 
keratitis  from,  150 
Koch-Weeks  bacillus  in,  150 
mercury  bichloride  in,  150 
metastases  in,  151 
micro-organisms  in,  150 
perforation  in,  150 
pneumococcus  in,  150 
prevention  of,  98 
protargol  in,  151 
salt  solution  in,  151 


Ophthalmia  neonatorum,  silver  nitrate  in' 

150,  151 

symptoms  of,  150 
treatment  of,  150 
vaccine  treatment  in,  151 
of  new-born,   150 
Ophthalmoplegia,  progressive,  528 
Ophthalmoscopic  examination  of  eyes,  75 
Opisthotonos  in  meningococcus  meningitis, 

469 

in  tetanus,  142 
Opium,  abuse  of,  114 

anti-diarrhceic  action  of,  114 
dose  of,  115 
extract  of,  115 
in  appendicitis,  115 
in  peritonitis,  115 
misuse  of,  115,  119 
secreted  in  milk  of  animals,  42 
tincture  of,  115 
value  of,  114 
wine  of,  115 

Optic  atrophy  in  familial  idiocy,  523,  524 
in  meningococcus  meningitis,  471 
in  serous  meningitis,  475 
in  syphilis,  785 

nerve,  medullation  of,  at  birth,  32 
neuritis  in  syphilis,  771 
Optochin  in  purulent  meningitis,  467 
Organic  diseases  of  nervous  system,  457 
Organisms  in  milk,  source  of,  55 
Organotherapy  in  treatment  of  anemia, 

173,  174 
Organs,  respiratory,  diseases  of,  Part  IV, 

p.  347 

Orthosis,  424 

Orthostatic  albuminuria,  154,  423 
Orthotic  albuminuria,  421 
age  in,  423 
diagnosis  of,  426 
nature  of,  425 
occurrence  of,  423 
pathogenesis  of,  425 
prognosis  of,  427 
sex  in,  423 
symptoms  of,  423 
synonyms  of,  422,  423 
tests  for,  425 
treatment  of,  427 
Osazone  test  for  sugar  in  urine,  293 
Osmosis  in  alimentary  intoxication,  295 
Osseous  system  in  scrofula,  731,  734 
Ossification,  centres  of,  29 
Osteitis,  rickitic,  191 
Osteochpndritis,  rheumatic,  709 
nokitic   101 

syphilitic,  709,  759,  760,  766,  768 
Osteogenesis  imperfecta  (Vrolik),  204,  237 
Osteoid  hyperplasia  in,  rickets,  196 
Osteomalacia  in  rickets,  191,  192,  196 
in  sepsis  of  new-born,  146 
juvenile,  205 

mistaken  for  infantile  scurvy,  190 
retropharyngeal  abscess,  in,  253 
Osteophytes,  development  of,  in  rickets,  196 


892 


INDEX 


Osteopsathyrosis,  237 
adrenalin  for,  238 
cod-liver  oil  for,  238 
fractures  in,  237 
phosphorus  for,  238 
Osteotabes  in  infantile  scurvy,  186 

myelogenous  infantile,  186 
Otitis  media,  acute,  356 

bacterial  flora  of,  357 
diagnosis  of,  357 
in  malnutrition,  299 
in  measles,  605,  612 
in  meningococcus  meningitis,  471 
in  serous  meningitis,  476 
in  typhoid  fever,  643 
paracentesis  in,  106,  359 
perforation  of  drum  in,  358 
prognosis  of,  358 
prophylaxis  of,  359 
symptoms  of,  357 
treatment  of,  359 
catarrhalis  neonatorum,  356 
chronic,  359 

syphilis  causing,  359 
treatment  of,  359 
tuberculosis  causing,  359 
Otogenous  brain  abscess,  496 
Otoscopy,  75 

Ott,  M.  D.:  Constitutional  anomalies  and 
diseases  of  metabolism,  Part  II, 
p.  156 

Pathological  changes  of  the  blood 
and  blood-forming  organs,  Part 
II,  p.  156 

Ovaries,  lactogen  of,  151 
Overcrowding,  danger  of,  104 
Overfeeding  dyspepsia,  258 

effects  of,  304 
Overwork  in  schools,  105 
Ovulation  following  weaning,  43 
Oxycephaly,  487 
Oxygen,  amount  used,  23 

asphyxia  of  new-born  treated  by,  127 

in  broncho-pneumonia,  376 

in  laryngeal  stenosis,  110 

in  meningococcus  meningitis,  extension 

of  meninges  by,  474 
lack  of,  in  treatment  of  anemia,  174 
supply  of  blood,  159 
unsaturation  of  blood,  395 
Oxyuris  vermicularis,  338 
Ozaena,  352 

P-R  TIME,  389 

P-wave,  391 

Pacifier,  dangers  from,  67 

infected,  99 

medicated,  in  treatment  of  thrush,  247 

uses  of,  67 
Pachymeningitis,  cranial  puncture  in,  457 

hemorrhagic,  477 

hemorrhagica  interna,  457 

internal  hemorrhagic,  cranial  puncture 
in,  457 


Pachymeningitis,    internal     hemorrhagic, 
treatment  of,  458 
retinal  hemorrhage  in,  457 
Packs,  cooling   107 

hot  dry,  in  abdominal  pain,  1 15 

in  insomnia,  115 

moist,   107 

sheet  in,  107 
Pads,  sucking,  8 

Pain,  abdominal,  compresses,  hot,  in,  115 
packs,  hot  dry,  in,  115 
poultices  in,  115 

development  of  sense  of,  32 

from  fissured  nipples,  treatment  of,  38 
Palsy,  infantile  cerebral,  499 
Pancreas,  amylolytic  secretion  of,  18 
Pancreatic  juice,  action  of,  10 
Pancreatitis  in  mumps,  687 
Pannus  of  cornea  in  scrofula,  732 
Panophthalmia  in  meningococcus  menin- 
gitis, 471 
Pap,  269 

Papilloma  of  larynx,  364 
Papular  tuberculide,  small,  of  infancy,  824 
Paracentesis,  abdominal,  80 

of  tympanic  membrane,  359, 
Paralysie  douloureuse,  518,  528 
Paralysis  agitans,  familial,  528 

cerebral,  499 

facial,  133,  528 

in  alimentary  intoxication,  292 

in  purulent  meningitis,  466 

in  serous  meningitis,  475 

infantile,  acute  epidemic,  510 
spastic  spinal,  506 

median,  528 

of  arm   528 

of  cranial  nerves  in  tuberculous  menin- 
gitis, 462 

of  eye  muscles  in  meningococcus  menin- 
gitis, 470 

of  new-born,  131 

of  serratus,  528 

paraplegic,  505 
bilateral,  505 

peripheral,  528 

peroneal,  526 

progressive,  570 
bulbar,  528 

pseudobulbar,  505 

radial,  528 

spinal,  510 

Paramyoclonus  multiplex,  553 
Paranoia,  570 
Paraphimosis,  452 

Parathyroids,  changes  in,  causing  rickets, 
194 

spasmophilia  and,  227 
Paratyphoid,  bacillus  paratyphosus  A  in, 
698 

B  in,  698 

bacteriologic  examination  in,  698 

diagnosis  of,  698 

in  infectious  intestinal  catarrh,  314 
Parenchyma,  lymphatic,  156 


INDEX 


.893 


Parenchyma,  myelotic,  156 

non-granular,  156 
Parents  of  premature  children,  125 

prophylactic  treatment  of,  in  syphilis, 

782 

Parotid  gland  in  mumps,  684 
Parotitis,  epidemic,  684 
Paroxysmal  hemoglobinuria,  166,  171 
Parrot's  paralysis,  132 
pseudoparalysis,  204 
Pars  villosa,  8 
Part,  special,  121 
Pasteurization  of  inilk,  56 

commercial,  not  to  be  recommended, 

56,  57 
home,  57 

"Pasty"  habitus,  215 
Patellar  reflex,  81 
in  chorea,  551 
in  purulent  meningitis,  466 
Pathogenesis,  general,  Chapter  IV,  p.  86 
Pathognomonic   symtoms  of  tuberculous 

meningitis,  464 
Pathological  changes  of  the  blood,  Part  II, 

p,  156 
of  the  blood-forming  organs,  Part  II, 

p.  156 

Patient  to  be  treated,  not  the  disease,  106 
Pavor  nocturnus,  353,  558 
Pearce,  N.  O.:    Diseases  of  the  new-born, 

Part  I,  p.  121 
Peculiarities,    anatomic    and   physiologic, 

Chapter  I,  p.  1 
Pedatrophy,  278 
Pediculosis,  815 

treatment  of,  816 
Pediculus  capitis,  815 
treatment  of,  816 
Pedonephritis,  437 
Pemphigus,  827 
acutus,  828 
foliaceus,  828 
neonatorum,  811,  812 

therapy  of,  813 
syphilitic,  758 
vegetans,  828 
vulgaris,  828 
course  of,  829 

differential  diagnosis,  of,  829 
etiology  of,  829 
prognosis  of,  829 
symptoms  of,  828 
treatment  of,  829 
Pen,  nursery,  68 
Penis,  infantile,  13 
Peppermint  lozenge  for  disguising  taste  of 

medicines,  119 
Pepsin,  117 

wine  of,  117 
Peptids,  10,  15 
Percussion,  mediate,  75 
Perforation  of  cornea  from    ophthalmia, 

150 

Periateritis  of  umbilical  stump,  136,  140 
Peribronchitis,  tuberculous,  727 


Pericardial  adhesions,  411 
diagnosis  of,  412 
liver  in,  412 
prognosis  of,  413 
symptoms  of,  411 
treatment  of,  413 
cavity,  puncture  of,  76 
Pericarditis,  acute,  407 
diagnosis  of,  409 
etiology  of,  407 
exudative,  409 
occurrence  of,  407 
paracentesis,  in,  410 
pathologic  anatomy  of,  407 
prognosis  of,  409 
purulent,  407 
rheumatic,  408,  409 
symptoms  of,  407 
treatment  of,  410 
tuberculous,  409 

in  meningococcus  meningitis,  471 
in  sepsis  of  new-born,  146 
obliterating,  405 
tuberculous,  in  scrofula,  734 
Pericardium,  tuberculosis  of,  in   scrofula, 

734 

Periodic  vomiting,  326 
Periorchitis,  453 
Periosteitis,  rickitic,  191 
Peripheral  nerves  of  new-born,  31 
nervous  system,  diseases  of,  528 
paralyses,  528 

Periphlebitis  of  umbilical  stump,  136,  140 
Peristaltic  movements  seen  through  abdom- 
inal walls,  79 

Peritoneum,  carcinoma  of,  346 
cysts  of,  346 
dermoids  of,  346 
diseases  of,  341 
echinococcus  of,  346 
inclusions  of,  346 
inflammation  of,  341,  342,  343,  344, 

345,  346 
sarcoma  of,  346 
syphilis  of,  346 
tumors  of,  346 
tuberculosis  of,  343 
in  scrofula,  734 
Peritonitis,  appendicial,  341 
chronic  exudative,  736 
fetal,  345 

from  lymphangitis  of  umbilical  vein,  141 
gonococcic,  343 

in  migratory  infection  of  umbilicus,  140 
opium  in,  115 
pneumococcic,  342 
purulent,  341,  342 
streptococcic,  343 
syphilitic,  346 

tuberculous,  in  scrofula,  734 
Pernicious  anemia,  arsenic  in,  173 

type  of  anemia,  167,  168 
Peroneal  paralyses,  528 
type,  progressive  neurotic  muscular  at- 
rophy, 526 


894 


INDEX 


Perspiration,  insensible,  23 

provoked  by  antipyretics,  107 
Pertussis,  672 

anatomy  of,  672 

attacks  in,  674 

bacillus  of,  672 
causing,  672 

agglutination  test  of,  672 

blood  in,  676 

Bordet  and  Gengou's  bacillus   in,  672, 
678 

broncho-pneumonia  in,  374,  672, 677, 678 

catarrhal  stage  of,  674 

causative  agent  in,  672 

complications  of,  676 

congenital,  673 

convalescence  in,  675 

convulsions  in,  677,  678 

convulsive  stage  of,  674 

cyanosis  in,  676,  677 

defecation,  involuntary,  in,  676 

definition  of,  672 

diagnosis  of,  679 

disease-picture  of,  673 

droplet  infection  in,  672 

duration  of,  675 

emphysema  in,  677,  678 

epistaxis  in,  677 

fever  in,  675,  676 

frenum  of  tongue,  injured  in,  676 

hygienic  measures  in,  681 

immunity  in,  673 

incubation  period  of,  674 

inguinal  hernia  from,  676  . 

measles  and,  677 

micturition,  involuntary,  in,  676 

mortality  from,  in  Bavaria,  572 
in  Prussia,  571 

pathogenesis  of,  672 

pathologic  anatomy  of,  672 

predisposition  to,  673 

prevalence  of,  673 

prognosis  of,  680 

prolapse  of  rectum  from,  676 

prophylaxis  of,  680 
vaccine  for,  681 

second  attacks  of,  673 

serous  meningitis,  in,  474 

sneezing  in,  675 

spasm  of  glottis  in,  678 

spread  of,  99,  100 

stages  of,  674 

symptoms  of,  676 

transmission  of,  672 

treatment  of,  681 

tuberculous  cough  similar  to,  726,  735 

vaccine,  dose  of,  681 

vomiting  in,  674,  675 

"whoop"  in,  674,  677 

X-ray  examination  of  bronchial  nodes 

in,  737 

Pes  valgus  in  rickets,  200 
Petit  mal  in  epilepsy,  545 
von  Pfaundler,  M.:   Constitutional  anom- 
alies and  diseases  of    metabolism 
Part  II,  p.  156 


von  Pfaundler,  M. :  Pathological  changes  of 
the  blood  and  blood-forming  or- 
gans, Part  II,  p.  156 
Pfeiffer's  bacillus,  700 
Pharyngeal  tonsil  in  meningococcus  men- 
ingitis, 468 

inflammation  of,  250,  351 
Pharyngitis  in  meningococcus  meningitis. 

467 
Pharynx,  diseases  of,  248 

tumors  of,  252 

Phenocoll,  hemocytolysis  from,  166 
Phenol   derivatives,   hemocytolysis    from 

166 

intolerance  of,  in  children,  119 
to  be  avoided  in  treating  sepsis  of  new- 
born,  147 
Phenolphthalein,  constipation  treated  by. 

112 

hemocytolysis  from,  166 
Phimosis,  13,  452 

surgical  treatment  of,  452 
Phlegmon,  in  malnutrition,  299 

preperitoneal,  140 
Phlyctenular,  conjunctivitis,  731 
Phobias,  561 

Phonendoscope,  use  of,  76 
Phosphorus  in  milk,  4,  5 

in  treatment  of  rickets,  206,  207 
tonic  action  of,  116 
Photophobia  in  scrofula,  733 
Physicians  as  carriers  of  disease,  100 
duties  in  contagious  diseases,  578 
school,  101 
Physiologic    and    anatomic    peculiarities, 

Chapter  I,  p.  1 
salt  solution,  296 

in  intestinal  infections,  319 
in  meningococcus  meningitis,  474 
Pia  in  meningococcus  meningitis,  468 

in  serous  meningitis,  474 
Physiology  of  metabolism,  15 

of  nutrition,  3 
Pills  to  be  crushed  before  administering 

in  young  children,  120 
Pin-worms,  338 

von  Pirquet,  C.  Frh.:  Diseases  of  the 
respiratory  organs,  Part  IV, 
p.  347 

Tuberculosis,  Part  IX,  p.  720 
von  Pirquet 's  cutaneous  tuberculin  reac- 
tion in  tuberculous  meningitis,  461 

not  a  contraindication  in  wet- 
nurse,  53. 
not    sufficient    to  stop    breast 

feeding  when  present,  37 
Pituitrin  in  alimentary  intoxication,  297 
Pityriasis  circinata,  831       . 
rosea,  831 

definition  of,  831 
diagnosis  of,  832 
etiology  of,  831 
symptoms  of,  831 
treatment  of,  832 

Placenta,  premature  separation  of,  causing 
asphyxia  of  new-born,  125 


INDEX 


895 


Placenta,  tuberculosis  of,  720 
Placques  erosive  779 
Platelets,  giant-cells,  origin  of,  156 
Plaut's  diphtheroid  angina,  251 
Plethora,  chlorotic,  163 
Pleura,  exploratory  puncture  of,  388 
tuberculosis  of,  728 
in  scrofula,  734 

Pleural  empyema  in  meningococcus  men- 
ingitis, 471 

tuberculosis,  722,  728 
Pleurisy,  383,  384 
fibrino-purulent,  383 
serofibrinous,  386 
course  of,  386 
diagnosis  of,  386 
exploratory  puncture  in,  387,  388 
treatment  of,  388 
Pleuritis,  serous,  736 
treatment  of,  388 
tuberculous,  722,  728 
Plumbism  causing  pseudo-anemia,  175 
Pluriglandular  insufficiency  of  Wiesel,  219 
Pneumococcic  conjunctivitis,  150 
meningitis,  467 
peritonitis,  342 

serum  in  purulent  meningitis,  467 
Pneumococcus     in     infectious     intestinal 

catarrh,  314 

in  purulent  meningitis,  465 
in  sepsis  of  new-born,  144 
in  spinal  fluid  in  serous  meningitis,  475 
Pneumonia,     apical,     in     meningococcus 

meningitis,  472 
aspiration,  374 
chronic,  381 
diagnostic  sign  of,  347 
lobar,  376 

auscultation  in,  378 
blood  in,  381 
complications  of,  380 
crisis  in,  379,  381 
diagnosis  of,  380 
frequency  of,  376,  377 
in  purulent  meningitis,  466 
localization  of,  377 
lung  in,  378 

meningitic  symptoms  in,  380 
prognosis  of,  380 
sputum  in,  378 
treatment  of,  381 
tuberculous,  728 

differentiation  from  lobar  variety,  728 
white,  of  syphilis,  asphyxia  in,'  126 
X-ray  examination  of  bronchial  nodes 

in,'  737 

Pneumonic  form  of  sepsis,  146 
Poisoning,  alimentary,  infective  from  diet, 

.294 

infectious,  irrespective  of  feeding,  294 
Poisons,  chemical,  action  of,  on  blood,  165 
ectogenous,  157 
endogenous,  157 
Pollakiuria,  420,  425 
Polioencephalitis,  primary,  492 


Poliomyelitis,  acute,  510 

coryza  in,  439 

course  of,  512 

diagnosis  of,  517 
differential,  517 

epidemiology  of,  510 

etiology  of,  510 

organism  of,  511 

pathologic  anatomy,  511 

paralysis  in,  513 

prognosis  of,  518 

symptomatology  of,  512 

treatment  of,  519 

Poliomyelo-encephalitis,   epidemic,   494 
Polyarthritis  acuta,  706 
Polychromasia,  161 
Polychromatophilia,  163 
Polycythsemia  in  alimentary  intoxication, 

293 

Polygraph,  390 
Polymorphonuclear  neutrophiles  in  blood 

of  new-born,  2 
Polymyositis,  529 
Polyneuritis,  529 
of  chickens,  19 
Polyorrhomenitis,  342 
Polyposis,  intestinal,  321 
Polysaccharides,  17 
Polyserositis,  342 

pneumococcic  peritonitis  in,  342 
Polyvalent    antimeningococcic    serum    in 

meningococcus  meningitis,  473 
Population,  growth  of,  86 
Poriomania,  562 
Port-wine  mark,  851 
Postdiphtheritic  cardiac  death,  653 
Post^hemorrhagic  anemia,  164,  165 
Postmortem  findings  in  nutritional     dis- 
turbances of  infants,  255 
Potassium  chlorate,  hemocytolysis  from, 

166 
iodide  in  purulent  meningitis,  467 

in  syphilis,  782 

in  tuberculous  meningitis,  465 
Potatoes,  mashed,  for  diabetics,  209 
Pott's  diseases,  differentiation  from  rick- 

itic  kyphosis,  204 
Poultices  in  abdominal  pain,  115 
Poverty,  affecting  morbidity  and  mortal- 
ity, 103 
anemia,  162 
Powders,  administered  in  milk,  120 

in  gruels,  120 
Precardia,  bulging  of,  75 
Predisposition  to  contagious  diseases,  574 
to  diseases,  213 
to  rickets,  196 
Pre-edema  of  Widal,  419,  432 
Pregnancy,  infrequent  in  nursing  women, 

43 
Premature  infant,  121 

anemia  in,  125,  161 

artificial  feeding  of,  124 

asphyxia  in,  126,  127 

bathing  of,  121 


896 


INDEX 


Premature  infant,  bottles,  hot  water,  for, 

122 
breast-milk  for,  123 

expressed,  for,  123 

breast-nursing,  difficulties  of,  in,  121 
buttermilk  for,  124 
calories  required  for,  123 
care  of,  121 
causes  of,  121 
chances  of  life  in,  121 
chilling   of    body-surface    of,    to    be 

avoided,  121 

clothes  basket,  receptacle  for,  122 
clothing  of,  122 
congenital  debility  in,  95 
Crede's  tubs  for,  122 
death  from  starvation  in,  121 
dextrin  for,  124 
diarrhoea  in,  124 
difficulties  in  rearing,  121 
disturbances  of  nutrition  in,  121 
diseases  in  mother  causing,  121 
earliest  age  of,  121 
expressed  human-milk  for,  123 
feeding  of,  123 
feedings,  number  of,  for  124 
fontanelles,  bulging  of,  in,  125 
heat,  artificial,  applied  to,  121 
hot  baths  for,  121 

water  bags  for,  122 

bottles  for,  122 
hydrocephalus  in,  125 
idiocy  in,  125 
incubators  for,  122 
automatic,  122 
temperature  of,  122 
intercurrent  infections  in,  121 
iron  for,  125 

lactation  in  mother,  difficulty  of  main- 
taining for,  124 
lightest  weight  of,  121 
Little's  disease  in,  125 
maltose  for,  124 
milk  dilutions  in,  124 
nervous  system  of  parents  of,  125 
pallor  in,  125 
parents  of,  125 
prognosis  in,  125 
rearing  of,  difficulties  of,  121 
rickets  in,  125 
sleeping  in,  124 
spasmophilia  in,  125 
subnormal  temperature  in,  122 
syphilitic,  121,  124 

feeding  by  wet-nurse  of,  124 
tendency  to  rickets  in,  125 

to  anemia  in,  125 

to  spasmophilia  in,  125 
viability  of,  121 
Preperitoneal  phlegmon,  140 
Pressure,  systolic,  in  adult,  2 

in  infant,  2 
Prickly  heat,  839 

Proctoclysis  in  intestinal  infections,  319 
Prof  eta's  law,  753 


Progressive  bulbar  paralysis,  528 
lordotic  dysbasia,  525 
muscular  dystrophy,  527 
neurotic    muscular    atrophy,    peroneal 

type,  526 

ophthalmoplegia,  528 
paralysis,  570 

spinal  muscular  atrophy,  infantile,  526 
torsion  spasm,  525 
Projection  fibres  at  birth,  31 
Prolapse  of  rectum,  335 

opium  for,  114 
Proprietary  foods,  59,  62 
Prosecretin,  10 

Protargol  in  ophthalmia  neonatorum,  151 
Protectors  to  nipples,  danger  of,  44 
Protein,  caloric  value  of,  20 

catarrh,  aggravated  by  too  much,  101 
cream-milk,  286 

digestion  in  severe  chronic  dyspepsia,  311 
in  sepsis  of  new-born,  144 
metabolized  per  body-weight,  64 
milk,  277,  285,  300,  302,  303 
advantages  of,  286 
in  acute  dyspepsia,  290 
in  chronic  dyspepsia,  313 
in  intestinal  infections,  319 
in  intoxications,  299 
powdered  form  of,  286 
preparation  of,  286 
nitrogen  in,  15 
of  human  milk,  10 
of  spinal  fluid,   increased  in  meningo- 

coccus   meningitis,    470 
in  tuberculous  meningitis,  464 
preparations,  artificial,  limited  value  of, 

117 
shock  therapjr  in  treatment  of  chronic 

rheumatism,  712 
toxic  action  of,  295 
Proteinuria,  421,  422 

intermittent,  prognosis  of,  426 
of  new-born,  154 
alimentary,  423 
cyclic,  422 
functional,  422 
hepatogenic,  423 
nephritic,  422 
orthostatic,  154,  423 
orthotic,  426 
prognosis  of,  427 
treatment  of,  427,428 
postural,  423 
pretuberculous,  423 

Proteus  bacillus  in  purulent  meningitis,  465 
Protolac,  286 

Prurigo,  216,  803,  807,  808. 
Pseudo-anemia,  174 

mistaken  for  chlorosis,  163 
Pseudo-ascites,  312,  345 
Pseudobulbar  paralysis,  505 
Pseudochlorotic  conditions,  163,  171 
Pseudocroup,  361 
diagnosis  of,  362 
etiology  of,  361 


INDEX 


897 


Pseudocroup,  in  measles,  601 
intubation  in,  362 
treatment  of,  362 
Pseudodiphtheria  bacillus,  638 

virulent  to  guinea  pig,  638 
of  new-born,  243 
Pseudoleucemias,  differentiation  from  Werl- 

hof's  disease,  178 
from  fulminative  purpura,  178 
from  sepsis,  178 
group  of,  175,  176 
Pseudoleukemic  anemia  in  syphilis,  775 

infantile  anemia,  168 
Pseudologia  phantastica,  555 
Pseudolues,  779 
Pseudo-melena,  148 
Pseudomeningitis,  464 
Pseudomeningocele,  traumatic,  491 
Pseudonuclein,  5 

Pseudoparalysis  in  infantile  scurvy,  188 
Pseudosclerosis  of  liver  in  Wilson's  dis- 
ease, 524 

Pseudotetanus,  544 
Psoriasis,  832 

treatment  of,  833 
X-rays  in,  834 

Psychic  development  of  child,  32 
disturbances    following   purulent    men- 
ingitis, 466 

effects  of  change  of  air,  118 
equivalents  in  epilepsy,  545 
impulses,  disturbances  of,  562 
stimulation  in  chronic  dyspepsia,  313 
support  of  galactagogues,  40 
traumata  causing  eclampsia,  541 

causing  anemia,  175 
treatment  of  exudative  diatheses,  224 
Psychopathic  constitution,  553 
Psychoses,  567 

acquired  defect,  569 
congenital,  567 
early  acquired  defect,  567 
without  defects  of  intelligence,  570 
Ptosis  in  tuberculous  meningitis,  462 
Ptyalin  in  saliva  of  new-born,  8 
Puberty,  blood-cells,  at,  2 
chlorosis  and,  163,  164 
heart  at,  2 

increase  of  weight  at,  26 
morbidity  of,  96 
mortality  of,  96 
tuberculosis  at,  733 
"Puerile"  breathing,  78 
Puerperal  infection,  dangers  of,  to  child, 

147 
sepsis,    breast   feeding   contraindicated 

in,  37 

Pug  nose,  779 

Pulmonary  tuberculosis,  chronic,  735 
antibodies  in,  735,  737,  738 
apices  in,  735 
auscultation  in,  736 
bloody  sputum  in,  735 
bones  in,  736 

bronchial  breathing  in,  735 
57 


Pulmonary  tuberculosis,  chronic,  bronchial 
nodes  in,  737 

broncho-pneumonia  in,  causing,  735 

cachexia  in,  736,  737 

calcified  foci  in  lungs  in,  736 

caseated  foci  in,  736 

cavity  formation  in  lungs,  in,  736 

clinical  demonstration  of,  736 

cough  in,  735 

death  from,  735 

diagnosis  of,  735 

diarrhoea  in,  735 

duration  of,  735 

ergines  in,  735,  737,  739 

fever  in,  735 

fluoriscopic  examination  of,  737 

fungus  joints  in,  736 

hairiness  of  skin  in,  736 

hectic  flush  in,  735 

hemoptysis  in,  735 

hoarseness  in,  735 

infectious  diseases  causing,  722,  735 

intestinal  tuberculosis  in,  735 

joints  in,  736 

laryngitis  in,  735 

lymph  nodes  in,  736,  737 

measles  in,  causing,  735 

meningitis  in,  736 

miliary  tubercles  in,  737 

percussion  in,  736 

peritonitis,  chronic  exudative  in,  736 

pertussis  in,  causing,  735 

pleuritis,  serous,  in,  736,  737 

polyadenitis  in,  735 

postmortem  findings  in,  735 

prognosis  of,  743 

prophylaxis  of,  744 

rales  in,  735,  736 

recovery  from,  735 

scars  in,  736 

serous  pleuritis  in,  736,  737 

spina  ventosa  in,  736 

spondylitis  in,  736 

sputum,  swallowing  of,  in,  737 

stenosis,  398 

symptoms,  first,  of,  735 

tertiary,  diagnosis  of,  736 

tubercle  bacilli  in,  737 
tuberculin  intracutaneous 
method  in,  738 
reaction  in,  737 
subcutaneous  method  in, 

738 

stage  of,  735 
X-ray  diagnosis  of,  736,  737 

tonsils,  finding  of,  tubercle  bacilli 
in,  by  staining,  737 

treatment  of,  745,  748 

tubercle  bacilli  in,  735,  736,  737 

tuberculin  reaction  in,  736,  737 

tympany  in,  735 

weight,  loss  of,  in,  735 

X-rays  in,  736 
Pulse  in  children,  2 

in  meningococcus  meningitis,  469 
in  new-born,  2 


898 


INDEX 


Pulse  in  tuberculous  meningitis,  461,  463 
periods,  390 
taking  of,  72 

Pumping  devices  to  empty  breast,  45 
Puncture,  cranial,  84 

in  articular  metastases,  151 
of  brain  in  cerebral  hemorrhage,  130 
of  ventricles  in  meningococcus  menin- 
gitis, 474 
sinus,  85 

Pupil  reaction,  first  appearance  of,  33 
Purpura  hemorrhagica,  184 

blood-platelets  reduced  in,  184 

thrombopenia  in,  184,  185 

treatment  of,  185 

Werlhof 's  type  of,  184 
Purulent  meningitis,  465 

atypical  cases  of,  466 

baths  in,  467 

blindness  from,  466 

brain  abscess  causing,  465 

covering,  inflammation  of,  in,  465 
inflammation  of,  in ,  465 

breast-feeding  in,  466 

chloral  in,  467 

Cohen's  bacillus  in,  465 

colon  bacillus  in,  465 

convulsions  in,  466 

coryza,  purulent,  in,  465 

deafness  from,  466 

diagnosis  of,  466 

diet  in ,  466 

diplococcus  lanceolatus  in,  465 

erysipelas  of  head  causing,  465 

ethyl  carbamate  in,  467 

ethylhydrocuprein  in,  467 

etiology  of,  465 

exudate  in,  465 

feeding  in,  466 

fever  in,  466 

fontanelles  in,  466 

fracture  of  skull  causing,  465 

fruit  juices  in,  436 

head,  cooling  of,  in,  467 

headache  in,  466 

hexamethylenamine  in,  467 

ice-cap  to  head  in,  467 

inflammation  of  brain  coverings  in, 
465 

influenza  bacillus  in,  465,  466 

latent  form  of,  466 

lobar  pneumonia  causing,  465 

lumbar  puncture  in,  466,  467 

mercurial  ointment  in,  457 

middle    ear,    focus  of  infection,   in, 
465 

narcotics  in,  467 

operative  interference  in,  467 

optochin  in,  467 

pain  in,  466 

paralyses  in,  466 

patellar  reflexes  in,  466 

pathogenesis  of,  465 

pathologic  anatomy  of,  465 

pneumococcus  in,  465 


Purulent  meningitis,  pneumococcus  serum 
in,  467 

pneumonia  in,  465,  466 

potassium  iodide  in,  467 

prognosis  of,  466 

proteus  bacillus  in,  465 

psychical  disturbances  from  466 

pupils  inequality  of,  in  466 

pyocephalus  in,  466 

pyocyaneus  bacillus  in,  465 

rest  in,  466 

rigidity  of  neck  in,  466 

scarlet  fever  causing,  465 

sensorium  in,  466 

skull,  fracture  of,  causing,  465 

somnolence  in,  466 

sopor  in,  466 

spina  bifida,  infection  of,  causing,  465 

spinal  fluid  in,  466 

staphylococcus  in,  465 

strabismus  in,  466 

streptococcus  in,  465 

stupor  in,  466 

thirst  in,  466 

tonic  spasms  in,  466 

treatment  of,  466 

tube-feeding  in,  466 

twitchings  in,  466 

typhoid  bacillus  in,  465 
Putrefaction,  266 
antagonistic  to  fermentation,  12 
injury,  259 

Pyelitis  in  tuberculous  meningitis,  464 
Pyelocystitis,  441 

in  malnutrition,  299 
Pyemia  in  sepsis  of  new-born,  146 
Pyloric  obstruction,  peristaltic  movements 

in,  79 

stenosis,  congenital  spastic,  322 
Pylorospasmj  simple,  322,  325 
Pylorus,  hypertrophic  stenosis  of,  322 
Pyocephalus  in  purulent  meningitis,  463 
Pyrogallol,  hemocytolysis  from,  166 
Pyogenic  bacteria  in,  general  sepsis,  715 

in  sepsis  of  new-born,  144 
Pyrexia  in  alimentary  intoxication,  292 
Pyrgocephaly,  487 

Q-WAVE,  389 

Qualitative  inanition,  treatment  of,  290 

Quest's  quotient,  282,  289 

Quiet  fits,  535 

Quincke's  theory  of  jaundice  of  the  new- 
born,  152 

Quinine  derivatives  in  fever,  107 
tonic  action  of,  116 
value  of,  in  fever,  107 

Quotient,  energy,  21 

R-WAVE,  389 
Rachischisis,  484 
Rachitic  children,  care  of,  102 
Rachmilewitsch 's  mustard  test,  in  exuda- 
tive diathesis,  218 
Radial  paralyses,  528 


INDEX 


899 


Radiation  increased  by  quinine,  107 

Radium  treatment  of  pigmented  nevi,  851 

Rage,  convulsive,  557 

Rate  blanche,  584 

Rales  in  tuberculosis,  735 

Ranula,  248 

Rash,  tooth,  248 

Reaction,  accommodation,  33 

of  milk,  4,  5 

pupil,  first  appearance  of,  33 
v.  Recklinghausen 's  disease,  528 
Rectum,  examination  of,  71,  81 

polypus  of,  in  intestinal  polyposis,  321 

prolapse  of,  335 

in  pertussis,  676 
opium  in,  114 

syringe  for,  111 

temperature  of,  71 

taking  of,  71 

Reflex,  blinking,  33 

corneal,  33 

gagging,  72 

in  meningococcus  meningitis,  470 

in  serous  meningitis,  475 

in  tuberculous  meningitis,  462 

light,  33 

motions  of  new-born,  33 

patellar,  81 

in  purulent  meningitis,  466 

pathologic,  558 

skin,  34 

sucking,  33 

tendon  of  new-born,  34 
Regenerative  anemia,  168 
Regimen  for  obesity,  211 
Re-lactation,  51 

Relatives,  marriage  of  close,  98 
Renal  abscesses,  439 
Respirations,  counting  of,  72 

disturbances  of,  110 

heart  stimulants  for,  110 

in  meningococcus  meningitis,  469 

in  tetanus,  142 

in  tuberculous  meningitis,  462 

number  of,  3 

stimulation  of,  110 
Respiratory  apparatus  in  new-born,  2 

catarrh  in  gastro-paresis,  310 

changes  in  rickets,  201 

convulsions,  emotional,  557 

organs,  diseases  of,  Part  IV,  p.  347 

troubles,  constitutional  resistance  to  be 

increased  in,  101 

transmitted  from  parent  to  child,  101 
volume,  3 

Retardation  of  development,  483 
Retinal   hemorrhage   in   internal   hemor- 

rhagic  pachymeningitis,  457 
Retinitis,  syphilitic,  770 
Retracted  nipples,  38 
Retronasal  angina,  249,  250 
Retropharyngeal  lymphadenitis,  252 
abscess  in,  252 
course  of,  253 
osteomyelitis  causing,  253 


Retropharyngeal     lymphadenitis,     treat- 
ment of,  253 

tuberculous,  253 
Revaccination,  633 
Reversion  in  decomposition,  279 
Rickets,  190 

abdomen,  distention  of,  in,  202 

pendulous  in,  192 
anemia  in,  162,  201 
antineuritic  principle  in,  19         . 
anti-rickitic  element  for,  207 
artificial  light  in,  206 
baths  in,  206 
bodily  exercise  in,  205 
bone-marrow,  fibrous  foci  of,  in,  192 
bones  in,  190,  191 
brain  in,  192 

hypertrophy  of,  in,  205 
bread  in,  206 
breast  feeding  in,  206 
bronchial  catarrh  in,  203 
broncho-pneumonia  in,  203,  204 
buttermilk  in,  206 
calcification,  in,  193,  194,  203 

lack  of  sufficient,  in,  191,  192 
calcium  contents  of  bone  in,  192 

of  blood  in,  192 

capillary  bronchitis  in,  203,  204,  205 
caput  quadratum  in,  200,  201,  204 
chemical  findings  in,  192 
chest,  short,  rounded  in,  192 
chicken  breast  in,  199 
chloromata  diagnosed  for,  205 
cod-liver  oil  in,  206,  207 
complications  of,  203 
contagious  diseases  in,  577 
course  of,  203 
coxa  vara  in,  200,  205 
craniotabes  in,  198,  200,  201,  203 
cranium,  periosteum  of,  in,  190,  191 
cross-bun  head  in,  200 
decalcification  in,  191,  194,  208 
decurvations  of  bones  in,  199,  200 
delay  of  dentition  in,  30 

of  walking  in,  33 
delayed,  205 
dentition,  delayed,  in,  198 

disturbance  of,  in,  201 
diathesis  of,  196 
dietary  in,  206 
differential  diagnosis  of,  203 
differentiation    from    infantile    scurvy, 

186,  189 

domestication  in,  195 
dwarfism  in,  203 
eburnation  in,  192 
eclampsia  in,  203 
endochondral  ossification,    disturbance 

of,  in,  191 

cndosteal  cells  in  bone-marrow  of,  192 
enteritis,  chronic,  in,  203 
Epstein  rocking-chair  in,  103,  205 
erythema ta  in,  202 
etiology  of,  194,  196 
extremities,  short,  plump,  in,  192 


900 


INDEX 


Rickets,  eye  complications  in,  203 

fat  soluble  A  vitamin,  prevention  of,  by, 

196 

feeding  as  a  cause  of,  195 
"fetal,"  204 

fibrous  foci  in  bone-marrow  in,  192 
flat  bones  in,  200 
fontanelles  in,  197,  201 
fractures  in,  199 
fresh  pir  in,  206 
from  chronic  dyspepsia,  309 
fruit  in,  206 
genu  valgum  in,  200,  205 

varum  in,  200 
head,  large,  in,  192 
hereditary  factors  in,  195 
hump-back  in,  203 
hypogenesis  ossium  in,  196 
hydrocephalus,  in,  204 
idiocy,  mongoloid,  in,  204 

Tay-Sach's,  in,  204 
infantile  paralysis,  atonic,  in,  204 
infections,  not  determining  factors  in, 

195 

infractions  in,  199,  200 
in  premature  children,  125 
in  run-about-age,  104 
internal    hemorrhagic    pachymeningitis 

in,  457 

Japan  free  from,  532 
jaw,  changes  of,  in,  199 
Kassowitz'  inflammation  in,  191 
kyphosis  in,  201,  203 
laryngospasm  in,  203 
liver  in,  192,  201 
lobular  pneumonia  in,  205 
lymph  nodes  in,  201 
lymphoid  tissue  in,  192,  201 
magnesium  salts  in  bones  of,  192 
massage  in,  206 
microscopic  changes  in,  191 
mineral  metabolism,  193,  194 
mineralization  of  cartilage  in,  193 

of  bone  in,  193 

mistaken  for  infantile  scurvy,  190 
mother's  milk  in,  193 
muscles  in,  192,  201 

mvatonia,  Oppenheim's  congenital,  con- 
tused with,  204 
myopathy  in,  192,  201 
myxedema,  congenital,  204 
nursing  in,  205 
nutritive  injuries  causing,  196 
occurrence  of,  194 
onset  of,  202 
open  fontanelles  in,  29 
organotherapy  in,  206 
orthopedic  interference  in,  207 
osteitis  in,  191 
osteoid  hyperplasia  in,  196 

tissue  in,  191 

osteomalacia  in,  190,  191,  196,  205 
osteophytes,  development  of,   in,    196, 

205 


Rickets,  parathyroids,  changes  in,  causing, 

194 

pathogenesis  of,  193,  196 
pathologic  anatomy  of,  190 
periosteitis  in,  191 
periosteum  in,  190 
perspiration  in,  202 
pes  planus  in,  205 

valgus  in,  200 
phalanges  in,  200 
phosphorus  contents  of  bone  in,  192 
phosphorus  in,  206,  207 
postmortem  findings  in,  190,  194 
Pott's  disease,  in,  204 
predisposition  to,  196 
progressive     amyotrophy,     infantile, 

mistaken  for,  204 
prophylaxis  of,  205 
pubic  angle  in,  199 
pulmonary  disturbances  in,  203 
recovery  in,  192,  203 
relation  to  scurvy,  194 

to  v.  Jaksch's  anemia,  194 
respiratory    disturbances    in,  201 
rosary  of,  200,  201,  203 
saber  tibia  in,  200 
saddle  head  in,  200 
scoliosesin,  199,  203 
scurvy  and,  204 
skeletal  manifestations  of,   196,   199, 

200 
skeleton,  changes  of,  in,  190,  201,  202, 

203 

soft  parts  in,  192 
softening  of  bones  in,  190 
soup  in,  206 
spasmophilia  and,  202 
spinal  column  in,  199 
spleen  in,  192,  201 
square  head  in,  200,  201,  204 
statistics  of ,  194 
sternum  in,  199 
sun  in,  206 
tarda,  205 

teeth,  delayed  development  of,  in,  198 
teething  in,  247,  248 
termination  of,  203 
tete  carre  in,  200,  201,  204 
theories  of,  193 
therapy  of,  205 
thigh,  deformity  of,  in,  201 
thoracic  changes  in,  199 
tonsils  in,  201 
ultra-violet  ray  in,  206 
urine  in,  202 

vasomotor  disturbances  in,  202 
vegetables  in,  206 
ventricular  dropsy  in,  205 
vitamins  in,  196,  207 

fat  soluble  A,  preventive  of,  196 
walking  delayed  in,  33,  197 
woolen  clothing  in,  206 
wrist-bones  in,  198,  200,  201 
X-ray  examination  in,  198,  204 


INDEX 


901 


Rickitic  rosary,  200,  201,  203 
Rigidity  of  neck,  in  meningococcic  menin- 
gitis, 468,  469,  472 
in  tuberculous  meningitis,  460 
Rheumatism,  acute  articular,  706 
chronic,  711 

ankylosis  in,  712 
differential  diagnosis  of,  712 
primary  form,  711 
prognosis  of,  712 
protein  shock  therapy  in,  712 
salicylates  in,  712 
secondary  form,  711 
Still's  variety  of,  712 
treatment  of,  712 
chorea  and,  551 
endocarditis  in,  400 
nodosum,  709 
pericarditis  in,  408,  409 
scarlatinal,  591 
serofibrinous  pleurisy  in,  386 
Rheumatoid  diseases,  709 
Rhinitis,  347,  350 

acute,  clinical  symptoms  of,  350 

treatment  of,  351 
hemqrrhagic,  457 
syphilitic,  757 
Rhinolalia  aperta,  654 
Rhinoliths,  354 
Rhinoscopy,  anterior,  75 
Rhubarb,    aromatic  syrup  of,   combined 

with  caster  oil,  112 
powder,  compound,  112 
Ribs,  position  of,  in  new-born,  3 
Rice  in  infant  feeding,  61 
polished,  causing  beriberi,  19 
powder  as  a  dusting  powder,  66 
Rieder's  cells  in  lymphatic  leucemia,  177, 

178 

Rigidity  of  neck  in  meningococcus  menin- 
gitis, 468,  469,  472 
in  tuberculous  meningitis,  460,  462 
Ring,  lymphatic,  248 
Ring  worm,  835 

of  body,  835,  836 
of  nails,  837 
of  scalp,  837 

Risus  sardonicus  in  tetanus,  142 
Rose  spots  in  typhoid  fever,  691,  692 
Rocking-chair  in  rickets,  205 

to  prevent  scoliosis,  102 
Rocking-horse  in  scoliosis,  102 
Roentgen  rays,  diagnostic  value  of,  85 

limitations  of,  85 
Roger's  disease,  396 
Rollier  treatment  of  tuberculosis,747 
Room  temperature  for  children,  67 
Rosary,  rickitic,  200,  201,  203 
Rotatory  spasms,  543 
Roteln  (German  measles),  616 
Round  worms,  337 

Rubber  band  to  neck  in  tuberculous  men- 
ingitis, 465 

Rubella  (German  measles),  616 
blood  in,  619 


Rubella,  diagnosis  of,  619 

diazo-reaction  absent  in,  260 

differential  diagnosis  from  measles,  619 

exanthem  of,  617,  618 

incubation  period  of,  617 

Koplik's  spots  absent  in,  619 

local,  620 

lymph   nodes,    swelling  of    superficial, 
in,  618 

organism,  unknown,  in,  617 

predisposition  to,  617 

prodromes  of,  617 

sine  eruptione,  619 

symptoms  of,  617 

temperature  in,  619 

treatment  of,  620 
Rubeola  scarlatinosa,  623 
Rubner's  dictum,  22 
Run-about-age,  care  of  children  in,  104 

rickets  occurring  in,  104 

S-WAVE,  389 
Saber  tibia  in  rickets,  200 
Saccharin  in  acute  dyspepsia,  290 
in  alimentary  intoxication,  296 
in  dyspepsia,  304 

in  first  feeding  of  the  new-born,  43,  49 
Saddle  nose  in  syphilis,  779 
Salaam  spasm  in  epilepsy,  545 
Salicylates  in  rheumatism,  710 
Salicylic  acid  secreted  in  milk,  42 

powder  for  dusting  purposes,  66 
Saline  laxatives,  112 
Saliva,  diastase  of,  18 

secretion  of,  in  children,  8 
Salivary  glands,  diseases  of,  248 

ranula  of,  248 
Salt  hunger,  18 

solutions,  enemata  of,  1 10 

enteroclysis,  method  of  using,  110,  111 
hypodermoclysis  of,  111 
intraperitpneal  injections,  111 
physiologic,   in    alimentary   intoxica- 
tion, 296,  297 

in  meningococcus  meningitis,  474 
rectal  use  of,  110,  111 
stimulating  action  of,  109 
subcutaneous  injections  of,  111,  297 
steam  in  treatment  of  bronchitis,  368 
Salvarsan  in  syphilis,  782 

in  ulcerative  stomatitis,  246 
Sanatogen,  40 
Sanitary  milk,  55 

Sarcomata  of  genito-urinary  tract,  456 
of  liver,  340 
of  peritoneum,  346 
Sarcoptes  hominis,  816 
Sauer's  farina  mixture,  272 
Scabies,  816 

acarus  scabiei  in,  816 
itch-mite  in,  816 
sarcoptes  hominis  in,  816 
treatment  of,  817 

Scalding,  hot-water  bottles,  dangers  from 
use  of,  108 


902 


INDEX 


Scaleni  muscle,  hematoma  of,  130 
Scaphoid  abdomen  in  meningococcus  men- 
ingitis, 469 

in  tuberculous  meningitis,  462,  463 
Scarlatina  (Scarlet  fever),  579 

sine  eruptione,  249,  588 
Scarlatinal  rheumatism,  591 
Scarlet  fever,  579 

agglutination  test  in,  580 
amaurosis  in,  592 
angina  in,  581,585,  588 

differentiation  from  diphtheritic  an- 
gina, 656 

diphtheroid,  in,  590 

necrotic,  in,  580,  589,  590,  595 
blood  in,  586 
blood-letting  in,  597 
blood-pressure  in,  592 
bronchitis,  purulent,  in,  591 
broncho-pneumonia,  in,  591 
causative  agent  unknown  in,  580 
clinical  picture  of,  582 
combined  with  chicken-pox,  577 

with  diphtheria,  576 

with  measles,  576 
complications  of,  588 
convulsions  in,  582 
deafness  from,  593,  597 
definition  of,  579 
delirium  in,  592 
desquamation  in,  584 
diagnosis  of,  593 
differentiation  from  glandular  fever, 

250 

dropsy  in,  592 

Dukes'  disease,  similarity  to,  594 
ear  affected  in,  590,  593,  597 
endocarditis  in,  400,  591 
endogenous  hemolytic  poison  in,  166, 
eosinophilia  in,  594 
eruption  in,  582,  583,  584,  585 

absent  in,  588 

erythema  post-scarlatinosum,  588 
etiology  of,  580 
fever  in,  582,  585,  592,  596 
finger-nails,  growth  of,  impaired  in, 

584 

fourth  disease,  similarity  to,  594 
fulminant,  589 

gastro-intestinal  tract  in,  592,  577,  588 
glomerular  nephritis,  acute,  in,  433 
heart  in,  591 
incubation  period  in,  581 
infection,  mode  of,  580 
joint  affections  in,  591 
Koplik  's  spots  absent  in,  594 
liver,  enlargement  of,  in,  586 
lumbar  puncture  in,  597 
lymph  nodes  in,  586 
mastoiditis  following,  590,  592,  597 
mortality  from,  in  Bavaria,  572 

in  Prussia,  571 
Moser's  serum  in,  597 
mouth  in,  585 
necrotic  angina  in,  580,  589  590,  595 


Scarlet  fever,  nephritis  in,  592,  593 
nose  in, 348,  349 
organism  unknown  in,  580 
otitis  media  in,  590,  597 
pathologic  anatomy  of,  581 
peculiarities  of,  588 
pericarditis,  purulent,  in,  591 
petechial  hemorrhages  in,  584 
phlegmon  in,  588,  589 
port  of  entry  in,  581 
predisposition  to,  581 
prognosis  of,  595 
prophylaxis  of,  595 
pulse  in,  586 
raie  blanche  in,  584 
rash  in,  582,  583,  584,  585 
respiratory  organs  in,  590 
rhagades  of  lips  in,  596 
rheumatic,  591 
rudimentary  forms  of,  588 
thrombopenia  in,  185 
second  attack  of,  434 
sequelae  of,  588,  592 
serum  disease  in,  666 

therapy  of,  597,  598 
spleen,  enlargement  of,  in,  586 
strawberry  tongue  in,  593 
streptococcus  in,  580,  582,  590 
throat  in,  585 
tongue  in,  585 

strawberry  in,  593 
tourniquet  test  in,  584 
toxic  type  of,  588 
transmission  of,  580 
traumatic,  581 
treatment  of,  595 
typhoidal,  592 
uremia  in,  592 
urine  in,  586,  597 
vomiting  in,  582,  586,  592 
Schick  reaction,  639 

age  in,  640 

School  anemia,  162,  163,  168 
children,  care  of,  105 
desks,  105 
diseases,  96 
fatigue,  causes  of,  105 
infection,  105 
inspection,  105 
overwork  in,  105 
physicians,  101,  105 
sickness,  212 
training,  106 

Schridde's  table  of  blood-cells,  156 
Schultze  's  method  of  resuscitation  in  as- 
phyxia, 126 
Science  of  feeding,  36 
Scleredema  of  new-born,  153 

differentiation  from  fatty  sclerema, 

153 

etiology  of,  154 
heat  in,  154 
mother's  milk  in,  154 
postmortem  findings  in,  153 
prognosis  in,  153 


INDEX 


903 


Scleredema  of  new-born,  treatment  of,  154 
Sclerema,  fat,  in  alimentary  intoxication, 

293 

in  new-born,  153 
postmortem  findings  in,  154 
Sclerosis  of  central  nervous  system,  510 
Scoliosis  from  manner  of  carrying  child,  68 
massage  in,  102 
permanent,  105 
preventable,  105 
prevention  of,  102 
rocking-chair  of  Epstein  in,  102 
rocking-horse  to  prevent,  102 
swing  in  preventing,  102 
Scratching  in  skin  diseases,  790,  799 
Scrofula,  730 

bones  in,  731,  734 

bronchitis  in,  730 

cachectic  habitus  in,  734 

catarrh,  chronic,  of  mucous  membranes 

in,  730,  733 
conjunctivitis  in,  731 
lymphatic,  in,  731 
phlyctenular,  in,  731 
cornea,  cloudiness  of,  in,  732,  734 
corneal  affections  in,  731,  732 
coryza  in,  733 
differentiation  from  leukemia,  731 

from  pseudo leukemia,  731 
ears,  in,  731 
ectropidn  in,  733 
eczema  in,  730,  732 
erethismic  habitus  in,  734 
eruptions  in,  733 
exudative  diathesis,  in,  730 
eyes  in,  731,  732,  733 
fistulae  from,  731 
habitus  in,  734 

phthisicus  of,  734 
leukemia,  differentiation  from,  731 
lichen  in,  733 
lips,  thickening  of,  in,  733 
lymp-nodes  in,  730 
lymphatic  system  in,  730 

cervical  enlargements  of,  730,  731 
lymphatism  in,  225,  730 
manifestations  of,  734 
mucous  membranes  in,  730,  731,  733 
nodes  in,  731 

of  ankle,  731 

of  brain,  735 

of  cornea,  731,732,  733 

of  ears,  731,  733 

of  epididvmis,  735 

of  eyes,  731,732,  733 

of  female  generative  organs,  735 

of  fingers,  731 

of  joints,  735 

of  lungs,  735 

of  mediastinum,  731 

of  neck,  730,  731 

of  nose,  731,733 

of  osseous  system  in,  731,  734 

of  peribronchial,  731 

of  pericardium,  734 


Scrofula,  nodes  in,  of  peritoneum,  734 
of  pleura,  734 
of  testes,  735 
of  vertebral  column,  735 
of  wrist,  731 

pannus  of  cornea  in,  732 

pericarditis,  adhesive,  in,  734 

peritonitis,  tuberculous,  in,  734 

phlyctenulae  in,  732 

photophobia  in,  733 

phthisical  habitus  in,  734 

pseudoleukemia,     differentiation    from, 
731 

pulmonary,  735 

pustules  in,  733 

rupture  of  foci  into  blood-stream,  734 

scars  following,  734 

sequestra  in,  731 

serous  membranes  in,  734 

symptom-complex  of  secondary  tuber- 
culosis, 730 

tears  in,  732 

termination  of,  734 

theories  of,  730 

tuberculides  in,  734 

tuberculous  origin  of,  730 

ulcers  in,  731,  732 

varieties  of,  730 
Scrofulides,  824 
Scrofutoderma,  819,  821 

definition  of,  821 

sunlight  treatment  of,  822 

treatment  of,  822 

X-rays  in,  822 
Scrofulous  children,  sea-salt  for  bathing  of, 

118 
sun-baths  for,  118 

eczema  in,  823 
Scurvy,   186 

a  food  disease,  19 

course  of,  189 

diagnosis  of,  188 

etiology  of,  186,  189 

epistaxis  in,  355 

from    commercial    pasteurization    of 
milk,  57 

infantile,  186 

occurrence  of,  189 

prognosis  of,  189 

symptoms  of,  186 

treatment  of,  190 

Scybala,  softening  of,  by  enemata,  111 
Sea  air,  effect  on  children,  102 

bathing  for  children,  102 

baths,  effects  of,  118 

salt  for  baths,  118 

Scammon,  Richard  Everingham:  Anatomic 
and  physiologic  peculiarities,  Chapter 
I,  p.  1 

Sebaceous  glands,  development  of,  14 
Seborrho3a,  788,  796 
Second  dentition,  30 
Secretin,  hormone,  10 
Secretion,  lachrymal,  absent  at  birth,  34 
Senna,  syrup  of,  laxative  action  of,  112 


904 


INDEX 


Senna,  syrup  of,  colic  from  112 
Sensation,  painful,  determination  of,  81 
Sense  organs,   complications  of,  in  men- 

ingococcus  meningitis,  471 
Sensorium  in  purulent  meningitis,  466 
Sepsis,  endogenous  hemolytic  poison,  166 
general,  715 
course  of,  717 
diagnosis  of,  719 
epistaxis,  from,  355 
fever  in,  717 
hemorrhages,  in,  718 
mucous  membranes,  hemorrhages  of, 

in,  718 

prognosis  of,  719 
prophylaxis  of,  719 
pyogenic  bacteria  in,  715 
skin,  hemorrhages  of,  in,  718 
symptom-complex  of,  715 
treatment  of,  719 
hemorrhages  in,  185 
mistaken  for  infantile  scurvy,  190 
Sepsis  of  new-born,  144 

antistreptococcus  serum,  useless,  in, 
148 

aural,  145 

autopsy  findings  in,  145 

baths  in,  148 

buccal,  145 

Buhl's  disease,  a  form  of,  146 

caffein  in,  148 

camphorated  oil  in,  148 

chills  absent  in,  146 

collapse  in,  146 

collargol,  useless,  in,  148 

conjunctival,  145 

contact  transmission  of,  145 

cutaneous,  145 

diagnosis  of,  146 

diarrhoea  in,  145 

differentiation  from  alimentary  in- 
toxication, 146 

emaciation  in,  145 

embolic  abscesses  in,  146 

endocarditis  in,  146 

epinephrin  in,  148 

erythemata  in,  146 

etiology  of,  144 

feeding  in,  147 

fever  in,  146    • 

gastro-intestinal  form  of,  146 

hemorrhages  in,  146 

hemorrhagic  form  of,  146 

icterus  in,  146 

in  artificially-fed  children,  145 

intestinal,  145 

iodoform  to  be  avoided  in,  147 

local  disturbances  causing,  145 

mastitis  as  a  cause  of,  147 

meddlesome  care  of  mouth  in,  145, 
147 

metastases  in,  146 

mother's  milk  in,  147 

mucous  membrane  in,  145 

nasal,  145 


Sepsis  of  new-born,  organisms  of,  144 
osteomyelitis  in,  146 
partum  forms  of ,  144 
pericarditis  in,  146 
pharyngeal,  145 
phenol  to  be  avoided  in,  147 
pneumonic  form  of,  146 
postpartum  forms  of,  145 
prognosis  of,  147 
prophylaxis  of,  147 
puerperal  infection  as  a  cause  of, 

147 

pulmonary,  145 
pyemia  of  joints  in,  146 
skin,  grayish  color  of,  in,  146 
sodio-salicylate  in,  148 
stimulation  of  heart  in,  148 
surgical  treatment  of,  147 
symptoms  of,  146 
tonsillar,  145 
toxemia  in,  145 
treatment  of,  147 
umbilical,  145 
urinary,  145 
uterine  form  of,  144 
Winckel's  disease,  a  form  of,  146 
Septic  icterus  of  new-born,  153 

infection  of  new-born,  141 
Septicemic  diseases,  715 
Serous  membranes  in  scrofula,  734 

in  tuberculosis,  728 
Serous  meningitis,  474 

angioneurotic  sequelae  in,  475 

apoplexia  serosa  in,  474 

baths  in,  476 

brain  in,  474 

chloral  hydrate  in,  476 

choked  disc  in,  475 

choroid  plexus  in,  474 

cold  douches  in,  476 

colon  bacilli  in  spinal  fluid  in,  475 

complications  of,  475 

convulsions,  eclamptic,  in,   474,  475 

convolutions   of   brain    flattened    in, 

474 

death  from,  475 
diet  in,  476 

eclamptic  convulsions  in,  474,  475 
ependyma  in,  474 
fever  in,  474,  475,  476 
fibrin  clot  in  spinal  fluid  in,  475 
fontanelles  in,  475 
fulminant  form  of,  474 
gastro-intestinal    disturbances,    caus- 
ing, 474 

headache  in,  475 
hexamethylenamine  in,  476 
hot  baths  in,  476 
hydrocephalus  acute,  in,  475 

chronic,  resulting  from,  475 
hypophysis,  injury  to,  in,  475 
infections  causing,  474 
influenza  bacilli  in  spinal  fluid  in,  475 

causing,  474 
intracranial  pressure  in,  475 


INDEX 


905 


Serous  meningitis,   limbs,    spasms  of,  in, 

475 

lumbar  puncture  in,  475,  476 
lymphocytes  in  spinal  fluid  in,  475 
measles  causing,  474 
meninges  in,  474 
mercurial  ointment  in,  476 
neck,  spasms  of,  in  475 
obesity  in,  following  injury  to  hypo- 
physis, 475 
optic  atrophy  in,  475 
otitis  media  in,  476 
paralysis  in,  475 
periorchitis,  453 
pertussis  causing,  474 

complicating,  475 
pia  in,  474 

pneumococci  in  spinal  fluid,  475 
pneumonia  causing,  474 
protein  content  of  spinal  fluid  in,  475 
recovery  from,  475 
reflexes,  increased  in,  475 
sexual  characteristics  retarded  in,  475 
sopor  in,  476 
spasmophilia  in,  475,  476 
spinal  fluid  in,  475 
staphylococci  in  spinal  fluid,  475 
strabismus  in,  475 
streptococci  in  spinal  fluid,  475 
symptoms  of,  474 
temperature  in,  474,  475 
termination  of,  475 
tetany  in,  475 
toxic  origin  of,  474 
treatment  of,  476 
tuberculous    meningitis    resemblance 

to,  475 

ventricles  distended  in,  474 
visual  disturbances  in,  475 
vomiting  in,  475 
Serratus  paralyses,  528 
Serum,  antitetanic,  143 
arsphenaminized,  784 
disease,  663,  789 
in  scarlet  fever,  665 
exanthem  in,  664 
reinjection  of  serum  causing,  664 
ectogenous  blood  poison,  166 
in  melena,  149 

in  meningococcus  meningitis,  472,  473 
in  umbilical  hemorrhage,  144 
urticarial  rashes,  caused  by,  805 
Sexual  characteristics  retarded  in  serous 

meningitis,  475 
development,  disturbances  of,  in  hypo- 

thyreoses,  231 

organs,  tuberculosis  of,  728,  735 
precocity,  teeth  in,  247 
Shiga's  bacillus  in  true  dysentery,  316 
Shingles,  827 
"Shooting  up,"  27 
Sickness,  sleeping,  494 
Sighing  respiration  in  alimentary  intoxi- 
cation, 292 
Sign,  D'Espine's,  78 


Silicic  acid  not  a  cause  of  scurvy,  189 
Silver  nitrate  in  eczema  of  nipples,  46 
in  fissured  nipples,  38 
in  ophthalmia  neonatorum,  150,  151 
in  umbilical  granuloma,  139 
Singer's  nodes,  364 
Sino-auricular  block,  391 
Sinus  puncture,  85 

thrombosis,  476 

Sit  up,  time  at  which  child  is  able  to,  32 
Six-year  molar,  eruption  of,  30 
Skeleton,  changes  of,  in  rickets,  190,  196 

growth,  of,  29 
Skin,  appendages  of,  diseases  of,  839 

atrophies  of,  847 

diseases  of,  Part  XI,  p.  787 
introduction  to,  787 

eczema  of,  788,  790 

edema  of,  acute  circumscribed,  803 

exudative  diathesis,  788 

grayish  color  of,  in  anilin  poisoning,  146 
in  sepsis  of  new-born,  146 

hyperesthesia  of,  in  tuberculous  men- 
ingitis, 459 

hypertrophies  of,  843 

in  alimentary  intoxication,  292 

in  meningococcus  meningitis,  469 

infectious  diseases  of,  834 

inflammations  of,  830 

irritation  of,  in  treatment  of  asphyxia, 
126 

lupus  of,  819 

navel,  134 

of  infant,  13 

delicacy  of,  120 

parasitic,  diseases  of,  815 

reflexes  of,  34 

seborrhcca  of,  788 

syphilis  of,  787 

tuberculosis  of,  721,  728,  729,  787,  818 

"turgor"  of,  14 

urticaria  of,  788 
Sleep,  of  infant,  35 

narcotics  for  producing,  115,  116 

of  new-born,  43 

soporifics  to  produce,  115,  116 
Sleeping  in  premature  children,  124 

in  the  open  in  treatment  of  anemia, 
174 

sickness,  494 

time  spent  in,  35 

Small-pox,  differentiation  from   varicella, 
628 

virus  vaccination,  630 
Smell,  development  of,  32 
Snake  venom,   ectogenous  blood  poison, 

166 

Snoring,  353,  670,  778 
Snuffles,  luetic,  352 

scrofulous,  352 
Soap  in  stools,  17,  267 

suppositories,  112 
Social  conditions  affecting  death-rate,  89, 

93,   103 
morbidity,  103 


906 


Sodium  benzoate,  stimulating  action  of, 
109 

bicarbonate  in  treatment  of  acidosis,  209 

citrate  in  treatment  of  acidosis,  209 

diethylbarbituate  in  alimentary  intox- 
ication, 297 

salts,  toxic  action  of,  295 

soporific  action  of,  116 

veronal  soporific  action  of,  116 
Solanum,  ectogenous  blood  poison,  166 
Somatose,  40 

Somnolence  in  purulent  meningitis,  466 
Sopor  in  meningocpccus  meningitis,  469 

in  purulent  meningitis,  466 

in  serous  meningitis,  476 
Soporific    type    of    alimentary    intoxica- 
tion, 294 

Soporifics,  115,  116 
Sores,  cold,  826 
Soups  for  weaning,  51,  52 
Soup-stock,  51 
Souring  of  milk,  5,  6 
Soxhlet-Henkel's  acidity  test,  56 
Spasmophilia,  530 

calcium  balance  in,  533 

cardiac  death  in,  537 

carpo pedal  spasms,  tetanic,  in,  536 

Chvostek's  sign  in,  531 

clinical  manifestations  of,  533 

complications,  537,  538 

convulsions  in,  533,  535 

course  of,  537 

death,  sudden,  in,  394 

definition  of,  530 

diagnosis  of,  530,  531,  538 

dietary  cause  of,  532 

differentiation  from  meningococcus  men- 
ingitis, 472 

duration,  537 

eclamptic  convulsions  in,  533,  535 

electric  hyperirritability  in,  530 

epilepsy  and,  538 

Erb's  phenomenon  in,  530 

etiology  of,  531 

facial  phenomena  in,  81 

fever  treatment  in,  108 

glottis,  spasm  of,  in,  533, 534 

in  chronic  dyspepsia,  309 

in  premature  children,  125 

in  serous  meningitis,  475 

laryngospasm  in,  533,  534 

metabolism  in,  533 

obstetrician's  hand  in,  536 

pathogenesis  of,  531 

pathognomonic  sign  of,  530,  531,  538 

pathologic  anatomy  of,  532 
peroneal  phenomena  in,  81 
physiologic,  34 
prognosis  of,  537 
respiratory  spasms  in,  533,  534 
rickets  and,  202,  532,  534 
status  lymphaticus  in,  537 

thymico-lymphaticus  in,  537 
teething  in,  248 
termination  of,  537 


Spasmophilia,  tetanic  spasms  in,  536 
tonic  convulsions  in,  533 
treatment  of,  538 
Trousseau's  phenomenon  in,  531 
tuberculous  meningitis  and,  464 
Spasms,  nutant,  543 
rotatory,  543 
tetanic,   142 
Spasmodic  tabes,  506 
Spastic  disease,  501,  503 

paraplegic,  503 
infantile  hemiplegia,  499,  501 

diplegia,  499,  503 
pyloric  stenosis,  congenital,  322 
spinal  paralysis,  hereditary,  528 

infantile,  506 
Speaking,  causes  delaying,  34 

time  of  first,  34 

Specific  gravity  of  blood  in  new-born,  2 
Speech,  time  of  acquirement,  34 
Sphacelus,  136 

Spices,  strong,  not  to  used  in  food  for  in- 
fants, 66 

Spina  ventosa,  736 
Spinal  bifida,  484 
anterior,  485 
occulta,  486 
column  in  rickets,  199 
cord,  diseases  of,  521 
growth  of,  31 
tumors  of,  521 
weight  of,  at  birth,  31 
fluid  in  meningococcus  meningitis,  470 
in  purulent  meningitis,  466 
in  serous  meningitis,  475 
in  tuberculous  meningitis,  465 
tubercle  bacilli  in,  475 
paralysis,  510 

hereditary  spastic,  528 
infantile  spastic,  506 

Spirochseta   in   membrano-ulcerative    an- 
gina,  251 
pallida,  750 

SpirochaBtes  in  ulcerative  stomatitis.  245 
Spleen,  hormone  of,  167 

in  meningococcus  meningitis,  469 
in  syphilis,  757,  758,  760 
in  typhoid  fever,  691,  692 
palpation  of,  79 
percussion  of,  79 
syphilis  of,  778 
tuberculosis  of,  729 

Splenectomy  in  Banti's  disease,  172,  174 
in  Biermer's  disease,  174 
in  Gaucher's  disease,  172 
Splenomegaly,  Gaucher's,  172 
Spondylitis,  tuberculous,  736 
Sponging,  cold,  in  fever,  107 
Sputum,  collection  of,  for  examination,  84 

tubercle  bacilli  in,  84 
Stammering,  353 
Standing,  not  to  be  hastened,  68 

time  of  child,  33 
St.  Vitus  dance,  549 
Staphylococcus  in  purulent  meningitis,  465 


INDEX 


907 


Staphylococcus  in  sepsis  of  new-born,  144 

in  spinal  fluid  in  serous  meningitis,  475 
Starch,  dusting  powder  of,  66 

enema,  vehicle  for  astringent  enemata, 

114 

polysaccharide,  17 
test  in  chronic  dyspepsia,  310 
Starvation  in  malnutrition,  303 
State's  duties  in  contagious  diseases,  578, 

579 
Statistics  of  births,  deaths,  and  still-births 

in  German  Empire,  87,  88 
Status  epilepticus,  547 
gastricus,  307 
lymphaticus  and  eczema,  803 

in  meningococcus  meningitis,  467 
in  spasmophilia,  537 
thymico-lymphaticus  215,  217,  220 

in  spasmophilia,  537 
Stearate    of    zinc    in    treating    umbilical 

wound,  136 
Stenosis,  aortic,  399 

congenital  intestinal,  329 

spastic  pyloric,  322 
mitral,  400 ' 

of  pylorus,  hypertrophic,  322 
pulmonary,  398 
tricuspid,  400 
Stereotypies,  555 
Sterility  of  gastro-intestinal  tract,  effects 

of,  12 

Sternberg's  disease,  176 
Sternocleidomastoid,  hematoma  of,  130 
palpation  of,  669 
respiratory  auxiliary  muscle,  669 
Stethoscope,  use  of,  76 
Stigmata  in  diathesis,  213 
of  degeneration,  567 
of  syphilis,  777,  778,  786 
Still-births  in  s.yphilis,  782 
Still's  disease,  712 
Stimulants,  circulation,  109 
caffein,  109 
camphorated  oil,  109 
digalen,  1 10 
digipuratum,  110 
digitalis,  109 
digitoxin,  soluble,  110 
epinephrin,  109 
saline  solutions,  109 
sodium  benzoate,  109 
strophanthus,  109 
respiratory,  110 

oxygen  for,  110 

Stimuli,  internal,  in  producing  skin  dis- 
eases, 789 

Stintzing  electrode,  82 
Stomach,  emptying  of,  112 

after  feeding,  10 
of  infant,  8 

capacity  of,  8 

casein  formation  in,  9 

curd  in,  9 

development  of,  8 

histological  structure  of,  9 


Stomach,  of  infant,  hydrochloric  acid  con- 
tents of,  9 

pepsin  contents  of,  9 
situation  of,  9 
tube,  feeding  by,  113 

in  dyspepsia,  309,  312 
in  meningococcus  meningitis,  473 
passing  of,  113 

technic  easier  than  in  adult,  79 
washing  of,  in  alimentary  intoxication, 

297 

in  dyspepsia,  312 
Stomachics,  alcohol,  in,  117 
Stomatitis,  242 
aphthous,  244 
diagnosis  of,  244 
pneumonia  in,  244 
septic  complications  of,  244 
treatment  of,  244 
bacterial,  242 
Bednar's  aphthae  and,  242 
catarrhal,  242 
chemical,  242 
complications  of,  243 
epithelial  pearls  in,  242 
from  meddlesome  care  of  mouth,  145 
gangrenous  (see  noma),  246 
hemorrhagic,  246 

in  scurvy,  246 
herpetic,  244 

treatment  of,  244 
infections,  general,  in,  242 
injuries  causing,  242 
measles  and,  242 

mouth,  meddlesome  care  of,  causing,  145 
prognosis  of,  243 
prophylactic  treatment  of,  243 
scarlet  fever  and,  242 
secondary  forms  of,  242 
septic,  244 

diphtheritic  forms  of,  243 
etiology  of,  243 
gangrenous  forms  of,  243 
thermal,  242 
thrush  in,  242 
ulcerative,  244 

differentiation  from  mercurial  stom- 
atitis, 245 

from  scorbutic  stomatitis,  245 
feeding  in,  245 
fetor  in,  245 
fusiform  bacilli  in,  245 
local  treatment  of,  245 
salvarsan  in,  246 
spirochaetes  in,  245 
teeth  in,  244 
treatment  of,  245 
Stools,  air,  action  of,  on,  11 

bloody,  in  infantile  scurvy,  187 

color  change  by  action  of  air  on,  11 

examination  of,  84 

flour,  274 

in  acute  dyspepsia,  289 

in  chronic  dyspepsia,  309,  311 

of  breast-fed  children,  303 


908 


INDEX 


Stools  of  infant,  11 
reaction  of,  11 
soap  in,  267 
Strabismus  in  meningococcus  meningitis, 

470 

in  serous  meningitis,  475 
in  tuberculous  meningitis,  462 
Strawberries,  urticaria,  caused  by,  804 
Strawberry  tongue  in  scarlet  fever,  593 
Streptococcus  in  enterocolitis,  315 
in  intestinal  tract,  314 
in  purulent  meningitis,  465 
in  sepsis  of  new-born,  144 
in  spinal  fluid  in  serous  meningitis,  475 
Stridor,  congenital,  360,  361 
Strophanthus,  stimulating  action  of,  109 
Strophulus,  803,  805 
albidus,  840 
impetiginosus,  806 
vesiculosus,  806 
Struma,  235 

iodine  in,  235 

Stupid  quarter  of  infant,  32 
Stupor  in  purulent  meningitis,  466 
Stuttering,  353 
Subcutaneous  injections  of  salt  solution, 

297 

Sublymphadenosis,    178 
Subnormal  children,  schools  for,  105 
temperature,  108 

camphorated  oil  in,  109 
caffeinin,  109,  110 
cardiac  weakness  in,  108 
coffee,  enemata  of,  in,  109 
collapse  in,  108 
Crede's  warming  tub  in,  108 
dehydration  in,  108 
demineralization  in,  108 
digalen  in,  110 
digipuratum  in,  110 
digitalis  in,  109 
electric  pad  in,  108 
enemata  of  coffee  in,  109 
epinephrin  in,  109 
heart  stimulants  in,  110 
hot-water  bottles  in,  108 
in  premature  children,  122 
incubator  in,  108 
medicines  in,  109 
mustard  bath  in,  108 

pack  in,  108 
Ringer's  solution  in,  108 
saline  solution  in,  108 
scalding  in  treatment  of,  108 
sodium  benzoate  in,  109 
strophanthus  in,  109 
tea  in,  109 
treatment  of,  108 
warming  tub  in,  108 
Substances  accessory  food,  19 
Suckling,  7,  8 
areola  in,  44 
duration  of  each,  46 
first  attempt  at,  44 
pads,  8 


Suckling  reflex,  33 
Sugar,  caloric  value  of,  20 

for  disguising  taste  of  medicines,  119 

in  infant  feeding,  64 

of  milk,  293 

excreted  in  urine,  208 

in  infant  feeding,  58,  60,  61,  62 

tests  for,  in  urine,  293 

toxic  action  of,  295 
Suggestive  therapeutics,  117 

for  bearing  down  pains  in  breast  or 

back,  37 

tenderness  of  the  nipples,  38 
Summary  of  infant  feeding,  64 
Summer  heat  as  a  cause  of  disease,  260 

mortality  higher  in,  89 
Sun-baths,  118 

in  anemia,  174 

in  rickets,  206 

Sunlight,  artificial,  in  treatment  of  anemia, 
174 

in  scrofuloderma,  822 
Suppositories,  glycerin,  112 

soap,  112 
Surface  of  body  in  relation  to  body  weight. 

14,  20 

Sweat  glands,  development  of,  14 
Sweating,  hot  tea  in  causing,  108 

precautions  to  be  used  in,  108 
Swing,  to  prevent  scoliosis,  102 
Symptomatology,    general,   Chapter  III, 
p.  70 

of  nutritional  disturbances,  262 
Symptom-complex,  treatment  of,  106 
Symptoms,  treatment  of,  106 
Syphilis,  Part  X,  p.  750 

abortion  in,  755 

acquired,  785,  786 

anemia  in,  167,  773,  775 

antibodies  in,  751 

arsphenamin  products  in  783 

blood  infection  of,  752 

bubo  in,  785 

caput  quadratum  in,  779 

causative  agent  of,  750 

cell  infiltration  in,  755,  761 

choroiditis  in,  771 

Colles'lawin,  753 

condylomata  in,  774 

congentia  sine  exanthemata,  766 

congenital,  754,  786 
fetal,  754,  755 
hemorrhages  in,  185 
infantile,  754,  757,775 
meningitis,  476, 

coryza  in,  757 

cure  of,  751,  785 

deafness  in,  777 

diagnosis  of,  777 

differentiation  from  small-pox.  765 

earthy  sallowness  of  skin  in,  762 

endarteritis  in,  771 

epistaxis  from,  355 

exanthemata  in,  758,  760,  761,  786 

feeding  in,  782 


INDEX 


909 


Syphilis,  fetal  infection  in,  752,  754,  755 
forehead,  protruding  in,  779 
gonitis  in,  777 

growth,  retardation  of,  in,  755 
gummatous  neoplasms  in,  774,  775 
hemorrhagic  rhinitis  in,  457 
hereditaria  tarda  sensu  strictiori/  778 
Hutchinson's  teeth  in,  777,  779 

triad  in,  777 

hydrocephalus  in,  770,  779 
in  premature  infants,  121,  124 
in  wet-nurse,  101 
incisors  in,  777 
incubation  period  of,  751 
infantile  paralysis,  progressive,  in,  777 
infantilism  in,  779 
infection,  modes  of,  in,  752 
internal  hemorrhagic  pachymeningitis, 

in,  457 

intraspinal  treatment  of,  784 
inunctions,  mercurial,  in,  783 
iodides  in,  782 
iritis  in,  770 
keratitis  in,  777 
lineal  radial  scars  in,  786 
lymph  nodes  in,  772 
maculopapular,  765 
marriage  and,  782 
maternal,  752,  753 
meningitis,  467 
mercury  in,  782,  783 

protoiodide  in,  783 
mistaken  for  infantile  scurvy,  190 
neoplasms,  gummatous,  in  774 
neosalvarsan  in,  783 
nephritis  in,  438 

nervous  system  in,  759,  760,  769,  776 
of  bones,  766,  776 
of  brain,  776 
of  eye,  770,  777,  785 
of  feet,  pustular  eruption  on,  757,  758, 

764,  765,  778 
of  hands,  pustular  eruption  on,  757, 758, 

765 

of  knee-joint,  777 
of  lips,  778,  785 
of  liver,  339,  340,  759,  760,  776 
of  nose,  349,  457,  757,  760,  779 
of  peritoneum,  346 
of  spleen,  778 
of  testes,  775 
of  viscera,  776 
optic  atrophy  in,  785 

neuritis  in,  771 
osseous  system  in,  731 
osteochondritis  in,  759,  760,  766 
paternal,  753 

pathologic  anatomy  of,  755 
pemphigus  in,  758,  760,  764 
phicques  erosive  in,  779 
premature  birth  in,  760 
primary  lesion  of,  752,  785 
Profeta's  law  in,  753 
prognosis  of,  781 
prophylactic  treatment  of  parents  in,  782 


Syphilis,  protoiodide  of  mercury  in,  783 
protozoa  in,  750 

cultivation  of,  750 

staining  of,  750 
pseudoleukemic  anemia  in,  775 
pug  nose  in,  779 
pustular  eruption  in,  757 
radial  lineal  scars  in,  785 
recurrences  in,  774 
reinfection  of,  751 
retinitis  in,  770 
rhinitis  in,  757,  760 
saddle  nose  in,  779 
salvarsan  in,  782 
scars  in,  778 

serum  arsphenaminized  in,  784 
skeletal  changes  in,  771 
snuffles  in,  39,  760,  778 
spirochseta  pallida  in,  750 

cultivation  of,  751 

dark  field  illumination  for  discovery 
of,  75 

staining  of,  750 

spleen,  enlargement  of,  in,  757,  758,  760 
stigmata  of,  778,  786 
still-births  in,  782 
•tabes  in,  777 
teeth  in,  777,  779 
temperature  in,  773 
treatment  of,  782 
treponema  pallidum  in,  750 

cultivation  of,  751 

staining  of,  750 

test  for,  751 
umbilical  ulcer,  resemblance  to  primary 

lesion  of,  137 
urine  in,  759 
vaccination  and,  632 
Wassermann  test  of,  751,  754,  779,  780, 

785 

waxy  pallor  of  skin  in,  762 
weight  in,  760 

white  pneumonia  of,  asphyxia  in,  126 
X-rays  of,  768 
Syringe,  rectal,  111 
Systolic  pressure  in  adult,  2 
in  infant,  2 

TABES  dorsalis,  521 
spasmatic,  506 

Tachycardia,  389 
anemic,  159 
paroxysmal,  389,  390 

Taka-diastase  in  chronic  dyspepsia,  313 

Talcum  with  sodium  salicylate  for  mum- 
mification of  umbilical  stump,  66 

Tannalbin,  114 

Tannic  acid,  diacetylic,  114 

Tannigen,  114 

Tannin,  astringent  action  of,  on  bowels, 
113 

Tannismuth,  114 

Tannoform,  114 

Tape,  measuring,  of  von  Pirquet,  28 
worms,  338 


910 


INDEX 


Tar  in  eczema,  800,  802 
Taste  organs  in  new-born,  33 

sense  low  in  young  children,  119 
Tay-Sachs'  idiocy,  523 

mistaken  for  rickets,  204 
Tea  in  alimentary  intoxication,  296 

in  dyspepsia,  304 
Teachers,  with  open  tuberculosis,  danger 

of  infecting  children,  101 
Technic  of  artificial  feeding,  58 

of  breast  feeding,  43 

of  examination,  Chapter  III,  p.  70 
Teeth,  anomalies  of,  247,  248 

appearance,  early,  of,  247 
retarded,  of,  247 

cleansing  of,  after  appearance  of  inci- 
sors, 67 

cutting  of,  29 

erupting,  order  of,  30 

green  deposit  on,  248 

grinding  of,  in  tuberculous  meningitis, 
460 

in  rickets,  198,  247,  248 

incisor,  first  to  appear,  30 

orthodontia  in,  248 

present  at  birth,  247 

rash  from,  248 

spasmophilia  from,  248 
Telangiectasis,  852 
Temperature,  axillary,  71 

bathing,  for  reducing,  106,  107 

body,  of  infant,  14 

development  of  sense  of,  32 

inguinal,  71 

normal  range  of,  14 

of  normal  child,  maintenance  of,  67 

of  room,  for  children,  67 

rectal,   71 

subnormal,  in  premature  children,  122 
treatment  of,  108 

taking  of,  71 
Temporal  vein  for  intravenous  injection, 

120 

Tendon  reflexes  of  new-born,  34 
Tenement  anemia,  162 
Tenia,  hemic  poison,  167 

saginata,  338 
Tooth  rash,  248 
Testes  affected  in  mumps,  687 

anomalies  in  position  of,  453 

tuberculosis  of,  735 

tumors  of,  456 

Test-meal  in  chronic  dyspepsia,  309,  312 
Tetanic  facies,  142,  536 

spasms,  142 

Tetanoid  condition,  530 
Tetanus  neonatorum,  142 

bacillus  demonstrated  in,  142 
breast-milk  in,  143 
bromides  in,  143 
chloral  hydrate  in,  143 
cyanosis  in,  142 
diagnosis  of,  143 
enteroclysis  in,  143 
etiology  of,  142 


Tetanus  neonatorum,  feeding  in,  143 
hyperpyrexia  in,  142 
incubation  period  of,  142 
magnesium  salts  in,  143 
opisthotonos  in,  142 
packs  in,  143 
prognosis  of,  143 
quiet  in,  143 

respiratory  disturbances  in,  142 
rigidity  in,  142 
risus  sardonicus  in,  142 
serum  therapy  of,  142 
spasms  in,  142 
symptoms  of,  142 
temperature,  rise  of,  in,  142 
tetanic  facies  in,  142 
treatment  of,  143 
trismus  in,  142 
umbilical  wound  responsible  for,  98, 

142 
Tetany  (see  Spasmophilia),  530 

latent,  530 

T&e  carre  in  rickets,  200,  201,  204 
Teterelle  biaspiratrice,  45 
Therapy  and  prophylaxis,  Chapter  V,  p.  98 

general,  106 

Thermocautery  in  hemorrhage  of  cord,  144 
Thermometer,  minute,  71 
Thiemich,  Martin :  General  considerations 
Chapter  I,  p.  1;  Chapter  II,  p.  36;  Chap- 
ter  III,  p.  70;   Chapter  IV,   p.  86; 
Chapter  V,  p.  98 
Thin-blooded,  160 
Thirst  in  purulent  meningitis,  466 
Thoracentesis,  exploratory,  79 
Thoracic  wall,  malformations  of,  3 
Thorax  compression  of,  in  treatment  of  as- 
phyxia of  new-born,  126 
of  new-born,  1,  3 
Throat,  examination  of,  71,  72 

method  of  holding  child  in,  72 
Thrombasthenia,  hereditary,  185 
Thrombocytolosis,  185 
Thrombopenia,  184,  185 
Thrombosis  of  cavernous  sinus,  457 
of  cranial  vessels,  490 
of  mesentery  in  chlorosis,  164 
of  umbilical  stump,  136,  140 
sinus,  476 
Thrush,  246 

embplic  abscess  in,  247 
feeding  in,  247 
gonidii  in,  247 
in  catarrhal  stomatitis,  242 
monilia  Candida  in,  247 
mouth-washing,  cause  of,  247 
pacifiers,  medicated  in,  247 
Thymus  gland,  dulness  of,  76 

hyperplasia  of,  in  exudative  diathesis 

215,  217,  218,  219 
hyperplastic,  asphyxia  of  new-born  from, 

126 

weight  of,  218 

X-raying  of,  in  treatment  of  psorias 
834 


INDEX 


911 


Thyroid  body,  226 

feeding  of,  in  hypothyreoses,  234 
in  treating  obesity,  dangers  of,  211 
pathology  of,  226 

preparations  of,  botulism  from,  234 
swelling  of,  in  pertussis,  676 
transplantation  of,  in  hypothyreosis, 

234 
Thyroxin,  234 

in  treatment  of  hypothyreoses,  234 
Time  spent  in  sleeping,  35 
Tinctures,  aromatic,  117 
Tinea,  capitis,  837 
circinata,  835 
cruris,  836 
favosa,  834 
tonsurans,  837 
trichophytina,  835 
capitis,  837 
corporis,  835 
cruris,  836 
Tolerance,  257,  261,  262 

tests,  420 

Tongue  blade,  use  of,  72,  73,  74 
depressor,  72,  73,  74 
geographical,  217 

rhythmic  traction  of,  in  asphyxia,  126 
strawberry,  in  scarlet  fever,  593 
Tonic  convulsions,  34 

spasms  in  meningococcus  meningitis,  469 
Tonics,  choice  of,  116 
Tonsils,  abscess  of,  250 
diseases  of,  248 
faucial,  249 
hyperplasia  of,  252 

in  exudative  diathesis,  215,  217 
hypertrophy  of,  in  scrofula,  731 
lymphosarcoma  of,  252 
pharyngeal,  acute  inflammation  of,  351 

in  meningococcus  meningitis,  468 
tuberculosis   of,    histology   of,  737 

primary,  721 
Torsion  spasm,  progressive,  524 

neurosis,  525 

Total  acidity  of  stomach  contents,  9 
metabolism,  19 
nitrogen  of  milk,  4 
Tourniquet  test  in  scarlet  fever,  584 
Tower  head,  487 

Toxic   breathing    in  alimentary  intoxica- 
tion, 292 

manifestations    in    nutritional    distur- 
bances, 289 

Toxicosis,  alimentary,  291 
Toxin  antitoxin  inoculation,  640 
Toxins  of  acute  intestinal  diseases,  hemic 

poisons,  167 

of  nephrosis,  hemic  poisons,  167 
Toxogenous  anemia,  166,  171 
Trachea,  catarrh  of,  364 
diphtheria  of,  649 

pressure  on,  by  tuberculous  nodes,  726 
Tracheal  lymph  nodes  in  tuberculosis,  726 

727 
Tracheobronchitis,  364 


Tracheotomy  in  laryngeal  diphtheria,  650> 

668 
in    obstruction    of    respiration    in  the 

larynx,  110 
Tragus,  pressure  on,  for  determining  pain 

in  external  auditory  canal,  75 
Training  of  child,  commencement  of,  69 

schools,   106 
Transfusion  in  anemia,  173 

in  purpura  hemorrhagica,  184 
Transitional  cells  in  children,  2 
Transmission  of  contagious  diseases,  572 
Transplantation  of  thyroid  in  hypothyie- 

oses,  234 

Transposition  of  great  vessels,  399 
Trapezius,  hematoma  of,  130 
Traumata,  birth,  127 

causing  asphyxia  of  the  new-born,  126 
psychic,  causing  anemia,  175 
Traumatic  pseudomeningocele,  491 
Tremor,  acute  cerebral,  493 
essential  hereditary,  528 
in  meningitis,  461,  472 
Trephine  in  cranial  puncture,  84 
Treponema  pallidum,  750 
Trichina  causing  polymyositis,  529 
Trichocephalus,  hemic  poison,  165 
Trichophytosis,  835 

corporis,  835 
Tricuspid  insufficiency,  405 

stenosis,  400 
Trismus  in  tetanus,  142 
Trommer's  test  in  meningococcus  men- 
ingitis, 470 

Trommsdorf  's  test  for  leucocytes,  56 
Tropholabile,  261,  289 
Trophostabile,  261 
Trophotoxic  anemia,  170 

treatment  of,  173 
Trousseau's  phenomenon  in  spasmophilia, 

531 

Trypsin,  9 

Tubercle  bacilli,  demonstration  of,  737 
by  antiformin  method,  737 
by  injection  in  guinea  pig,  737 
in  spinal  fluid,  475 
in  stools,  737 
in  tonsils,  737 

obtaining  of,  for  examination,  737 
Tubercle,  median  labial,  8 
Tuberculide,  819 
of  skin,  728 
papular,  824 
papulo-necrotic,  824 
papulosquamous,  824 
Tuberculin  coryza,  349 
old,  subcutaneous  injections  of,  738 
conjunctival  instillation  of,  738 
cutaneous  vaccination  of,  738,  739, 

740 

focal  reactions  of,  738 
general  reactions  of,  738 
intracutaneous  injections  of,  738 
negative  reactions  in,  738,  741 
percutaneous  inunction  of,  738,  741 


912 


INDEX 


Tuberculin  old,  positive  reactions  in,  739, 

740,  741 
theories  of  reaction  in,  737,  738 

reaction,  729,  737 

by  conjunctival  instillation,  741 
by  cutaneous  vaccination,  738,  739 
by  intracutaneous  method,  738 
by  percutaneous  inunction,  738,  741 
by  subcutaneous  method,  738,  740 
in    chronic    pulmonary   tuberculosis, 

738,  735 
in  cow,  55 

in  tuberculosis,  720,  723,  724 
lacking  in  eruption  of  measles,  613 
method  of  obtaining,  737 
signification  of,  738,  742 
treatment,  748 
Tuberculosis,  Part  IX,  p.  720 

acquired,  720,  721 

activated  by  measles,  577 

age  of  infection  in,  720 

allergy  in,  722 

anemia  in,  162,  167 

antibodies  in,  722,  735,  737 

apotoxins  in,  738 

bacillus  of,  720 

bovine  type,  720 
human  type,  720 

breast  feeding  in,  37 

bronchial  lymph  nodes  in,  726 

calcification  in,  721 

cavernous  pulmonary,  720,  723,  728 

cavity  formation  in  lungs  in,  720,  723 

cervical,  730 

chicken-pox,  effect  of,  in,  722 

chronic  pulmonary,  735 

clinical  manifestation  of,  723,  724,  725 

congenital,  720,  721 

cough  in,  726 

resemblance   to  that  of  pertussis, 
726,  728 

cow's  milk,  unboiled,  causing,  721 

cutaneous,  729 

cyanosis,  in,  726 

death-rate  from,  94,  723 

d  'Espine  '&  sign  in,  726 

distribution  of,  by  lymph-channels,  722 
blood,  722 
irregular,  723 

drumstick  fingers  in,  726 

ergines  in,  735,  737 

erythema  nodosum  in,  728 

fetal  infection  of,  720 

frequency  of,  723 

gastro-intestinal,  720,  721 

general  miliary,  458 

glandular,  724 

hard  work,  effect  of,  on,  722 

hematogenous,  723 

hemorrhages  in,  185 

hereditary  taint  in,  735 
transmission  of,  720 

human  type  of,  720 

infection  in,  age  of,  in,  720 
mode  of,  721 


Tuberculosis,  infectious  diseases,  effects  c 

on,  722 

inheritance  of,  720 
intestinal,  720,  721,  722 
Koch's  discoveries  in,  720 
latency  of  infection  in,  720,  723 
lichen  in,  728 
lymph  nodes  in,  721,  723,  726 

cervical,  730 

mesenteric,  730 

palpation  of,  726 

percussion  of,  726,  727 

pharyngeal,  730 

rupture  of,  into  bronchus,  727 

sublingual,  730 

tonsillar,  730 
lymphogenous,  723 
measles  effect  of,  on,  722 
mesenteric,  730 
miliary,  728,  729 

spread  of,  728 

nodules  in,  721 
mode  of  infection  in,  720,  721 
of  apex,  721 

of  bone,  458,  724,  728,  729 
of  bronchi,  722 
of  bronchial  lymph  nodes,  721 
of  cheek,  primary,  721 
of  choroid,  729 
of  conjunctiva,  secondary,  722 
of  different  lobes,  721 
of  intestines,  722 
of  joints,  458,  724 
of  lungs    (see    Pulmonary    tuberculosis 

primary),  727 

of  mesenteric  lymph  nodes,  343,  722 
of  mouth,  722,  729 
of  mucous  membranes,  721,  729 
of  nose  primary,  721 

secondary,  722 
of  peritoneum,  343,  722 
adhesive  form  of,  344 
diagnosis  of,  344 
exudative  form  of,  344 
treatment  of,  345 
of  pleura,  722,  728 
of  poor,  724,  725 

of  retroperitoneal  lymph  nodes,  343 
of  rich,  724,  725 
of  serous  membranes,  730 
of  sexual  organs,  729 
of  skin,  721,728,  729,  818 
of  spleen,  729 
of  tonsil,  primary,  721 
of  udder,  56 
of  upper  air  passages,  729 
open,  723,  725 

in  school  children,  101 

in  teacher?,  101 
peribronchitis  in,  726 
pharyngeal,  secondary,  730 
phlyctenulae  in,  728 
placental,  720 
pleuritis  in,  728 
pneumonia  in,  728 


INDEX 


913 


Tuberculosis,  postmortem  findings  in,  720, 

721,  723,  724,  726,  728,  735 
predisposition  for,  720 
pregnancy  in,  722 
prevention  of,  in  children,  100 
primary  lesion  of,  720,  721,  723 
primary  stage  of,  723,  725 
anemia  in,  725 
emaciation  in,  725 
fever  in,  725 
night  sweats  in,  725 
pubertal,  723 
pulmonary,  721,  722 

cavernous,  720 
reinfection  in,  722 
rupture  of  caseating  node  into,  727 
scrofula  (q.  v.),  a  symptom-complex  of, 

730 

secondary  stage  of,  723,  728 
spread  of,  in  body,  721 
stages  of,  723 
statistics  of,  723,  724,  725 
subcutaneous,  729 
sublingual,  730 
tertiary  stage  of,  723,  735 
test,  729 

tonsillar,  secondary,  730 
tracheal  lymph  nodes  in,  726 

pressure  in,  726 
transmission  of,  720 
tuberculides  in,  728 

tuberculin  reaction  in,  720,  723,  724,  825 
ulcers,  intestinal,  in,  722 
Widal  test  in  suspected  miliary,  729 
work,  hard,  effect  of,  on,  722 
X-rays  in  enlarged  nodes  in,  726,  727 

in  miliary,  729 
Tuberculous  children,  open-air  schools  for, 

105 

empyema,  386 
meningitis,  458 

atypical  course  of,  463 

auditory  stimuli  increased  in,  459 

bed-sores  in,  462 

brain  tumor  in,  464 

Brudzinski  's  sign  in,  460 

carpopedal  spasm  in,  464 

Cheyne-Stokes  breathing  in,  462 

chloral  hydrate  for,  465 

choked  disc  in,  462 

choroidal  tubercles  in,  462,  464 

Chvostek  phenomenon  in,  464 

clinical  picture  of,  459 

clonic  epileptiform  convulsions  in,  463 

coma  in,  463 

cough  in,  459 

course  of,  459 

death  in,  464 

dermatographia  in,  460,  464 

diagnosis  of,  463 

diazo-reaction  in,  464 

diet  in,  465 

duration  of,  463 

emaciation  in,  462 

erythemata  in,  460 

;  ss 


Tuberculous  meningitis,  etiology  of,  458 
eyes  in,  462 

facial  phenomenon  in,  464 
fontanelle,  bulging  of,  in,  463 
grinding  of  teeth  in,  458 
headache  in,  459 

relief  of,  in,  465 
hectic  flushes  in,  459 
hemiplegia  in,  463 

crossed  in,  463 

hereditary  predisposition  to,  459 
hydrocephalic  cry  in,  461 
hyperesthesia  of  skin  in,  459 
hyperpyrexia  in,  459 
improvement  in,  464 
intracranial  pressure  in,  461 
iodoform  for,  465 
Kernig's  sign  in,  460,  463 
loss  of  weight  in,  459 
lumbar  puncture  in,   457,  458,  461, 

464,  465 

measles  and,  458 
mercurial  ointment  for,  465 
meteorism  in,  464 
monoplegia  in,  463 
nutrient  enemata  in,  465 
nystagmus  in,  462 
obstipation  in,  459,  463 
paralytic  symptoms  in,  461 
pathogenesis  of,  458 
pathognomonic  symptoms  of,  464 
pathologic  anatomy  of,  458 
pertussis  and,  458 
v.  Pirquet  's  test  in,  461 
potassium  iodide  for,  465 
pressure,  intracranial,  in  461 
prognosis  of,  464 
ptosis  in,  462 
pulse  in,  461,  463 
pupils  in,  460,  462 
pyelitis  in,  464 
quiet  in,  465 
recovery  in,  462 
reflexes  in,  462 
respiration  in,  462,  463 
retention  of  urine  in,  463 
retracted  abdomen  in,  462 
rigidity  in,  460,  462 
rubber  band  to  neck  in,  465 
scaphoid  abdomen  in,  462,  463 
sighing  respiration  in,  463 
spasmophilia  and,  464 
spinal  fluid  in,  464 
stools  in,  459 
strabismus  in,  462 
swallowing,  difficult,  in,  462 
temperature  in,  459 
tetany  in,  464 
trauma  in,  458 
treatment  of,  464 
tube  feeding  in,  465 
tubercle  bacilli  in  spinal  fluid,  464 
typhoid   fever,    differentiation   from, 

464 
uremia  and,  464 


914 


INDEX 


Tuberculous  meningitis,  urine,   examina- 
tion of,  in  suspected,  464 

visual  stimuli  increased  in,  459 

vomiting  in,  459,  460 

weight,  loss  of,  in,  458 

winking  in,  462 

yawning  in,  460 

Tuberculous  peritonitis  in  scrofula,  734 
Tubular  nephropathy,  428 

course  of,  429 

diphtheritic,  430 

etiology  of,  428 

patho  genesis  of,  428 

pathology  of,  428 

prognosis  of,  429 

symptomatology  of,  428 
Tumor,  cerebral,  497 

of  brain,  in  tuberculous  meningitis,  464 
of  genito-urinary  tract,  455 
of  pharynx,  252 
Turgor  of  infant's  skin,  14 
Twins,  anemia  in,  161 

nursing  of,  47 
Tympanic  membrane,  examination  of,  75 

of  new-born,  355 

Tympanum,  purulent  matter  in,  356 
Typhoid  fever,  688 

abscesses  of  skin  in,  694 

agglutination  test  in,  695 

antityphoid  vaccination  in,  696 

bacillus  typhosus  in,  688 

in  purulent  meningitis,  465 

blood  in,  691 

bowel  movements  in,  691 

breast  feeding  contraindicated  in,  37 

bronchitis  in,  691,  692 

broncho-pneumonia  in,  693 

carriers  in,  688 

causative  organism  of,  688 

clinical  picture  of,  689 

complications  of,  692 

congenital,  689 

decubitus  in,  694,  696 

definition  of,  688 

diagnosis  of,  694 

differential,  from  appendicitis,  694 
from    meningococcus  meningitis, 

472 
from  miliary  tuberculosis,  698 

diarrhoea  in,  692 

diazo-reaction  in,  695 

digestive  system  in,  692 

endogenous  hemolytic  poison,  166 

epidemics  of,  689 

epistaxis  in  354,  693 

erythema  of  skin  in,  693 

fever  in,  690 

gall-bladder  in,  688 

heart  in,  691,  693 

hemorrhages,  intestinal,  in,  698 

hydro  therapy  in,  697 

kidneys  in,  693 

liver  in,  693 

meteorism  in,  691,  692 

nervous  system  in,  691,  693 


Typhoid  fever,  osseous  system  in,  694 

otitis  media  in,  693 
parotid  gland  in,  693 
pathologic  anatomy  of,  689 
predisposition  to,  689 
prodromes  in,  690 
prognosis  of,  692,  695 
prophylaxis  of,  695 
recurrences  in,  694 
respiratory  tract  in,  693 
rose  spots  in,  691,  692,  693 
sera  in,  696 
skin  in,  693 

spleen,  enlarged,  in,  691,  692 
tongue  in,  690,  692 
transmission  of,  688 
treatment  of,  696 

dietetic,  696 

physical,  696 
vaccination  in,  696 
vomiting  in,  692,  693 
Widal  agglutination  test  in,  695 
Typhoid-like  gastro-enteritis  in  intestinal 
tract,  315 

UDDER,  cleanliness  of,  55 

tuberculosis  of,  56 
Uffenheimer's  tetanic  facies,  536 
Ulcer,  corneal,  in  scrofula,  732 
of  umbilical  wound,  135,  137,  139 
of  umbilicus,  137,  139 
diphtheria  of,  139 

treatment  of,  139 
tuberculous  intestinal,  722 
Ultra-violet  ray  in  treatment  of  rickets, 

206 
Umbilical  cord,  anatomy  of,  133 

compression  of,  causing  asphyxia  of 
new-born,   125 

hernia  of,  134 

mummification  of,  133,  134,  135 

separation  of,  133 
fungus,  139 
hemorrhage,  143 

bleeding  time  in,  144 

coagulation  time  in,  144 

epinephrin  in,  144 

gelatin  solutions  in,  144 

idiopathic,  143 

serum,  human,  for,  144 

thermocautery  in,  144 

whole  blood  in,  144 
hernia,  134,  337 

funicular,  134 

ring,  acute  inflammation  of,  139 
stump,  abscess  of,  140 

adenomata  of,  139 

bismuth  subgallate  for,  136 

blenorrhoea  of,  135,  136,  137,  139 

bolus  alba  sterilized  for,  136 

chloracetic  acid  to,  139 

dry  method  of  treating,  136 

enteroteratomata  of,  139 

fungus  of,  135,  139 

gangrene  of,  135,  136,  140 


INDEX 


915 


Umbilical  stump,  granuloma  of,  139 

migratory  infection  of,  140 

mummification  of,  134,  135 

omphalitis  of,  135 

periarteritis  of,  136 

periphlebitis  of,  136 

silver  nitrate  to,  139 

thrombosis  of,  136 

stearate  of  zinc  for,  136 

ulcer  of,  135,  137 
ulcer,    137 

vein,  lymphangitis  of,  140 
wound,  134 

asepsis  of,  66 

baths,  dangers  from,  in  institutions 
in  treating,  136 

bismuth  subgallate  for,  66 

blenorrhcea  of,  135, 136,  137,  139 

bolus  alba  for,  66 

care  of,  66 

delayed  healing  of,  136 

diphtheria  of,  139 

drying  powders  in,  66 

fungus  of,  136 

gangrene  of,  136,  140 

mild  diseases  of,  136 

moist  dressing  to  be  avoided,  66 

omphalitis,  circumscribed,   136 

periarteritis  of,  136 

periphlebitis  of,  136 

severe  diseases  of,  136 

talcum  with  sodium  salicylate  for,  66 

tetanus  from,  98,  142 

thrombosis  of,  136 

treatment  of,  136 

ulceration  of,  136 

Umbilicus,  anomalies,  congenital,  of,  134 
diphtheria  of,  139 
diseases  of,  133 

endarteritis  obliterans  of  vessels  of,  134 
excoriation  of,  137 
.     fistula  of,  135 
fungus  of,  139 
gangrene  of,  135, 140 
granuloma  of,  139 
hemorrhage  of,  142 
infections  of,  135 

Meckel's  diverticulum,  patent,  at,  135 
persistence  of  omphalomesenteric  duct 

at,  135,  139 
pyodermia  around,  137 
ulcer  of,  139 

treatment  of,  139 
wound  of,  133 
Uncontrollable  acts,  561 

ideas,  561 

Under-nourished  children,  211 
United  States,  deaths  of  infants  under  one 

year  in,  1918,  88 
Urachus,  fistula  due  to  persistence  of,  135, 

139 

Uremia,  420 
azotemia  in,  421 
due  to  nitrogen  retention,  421 
eclamptic,   420 
lumbar  puncture  in,  421 


Uremia,  sleeping,  421 

treatment  of,  421 
Ureters,  catherization  of,  80 
Urethra,  infection  of,  by  gaping  of  vulva, 

13 

Uric  acid  infarcts  of  kidneys,  13,  154 
Urinary  tract,  purulent  diseases  of,  439 
Urine,  characteristics  of,  at  birth,  12 

collection  of,  for  examination,  80 

examination  of,  419 

in  alimentary  intoxication,  293 

in  arthritism,  222 

in  meningococcus  meningitis,  469 

in  tuberculous  meningitis,  464 

Nylander's  test  in,  293 

quantity  of,  420 

osazone  test  in,  293 

retention  of,  in  tuberculous  meningitis, 
463 

Trammer's  test  in,  293 
Urobilin,  formation  of,  166 
Urticaria,  788,  803 

eggs  causing,  804 

food  causing,  804 

giant,   805 

itching  in,  804 

lobster  causing,  804 

of  mucous  membranes,  804 

ordinary,  803,  804 

papulosa,  803,  805 

gigmentosa  definition  of,  825 
differential  diagnosis,  826 
etiology  of,  826 
prognosis  of,  826 
symptoms  of,  826 
treatment,  of  826 

porcellanea,  803 

relation  to  strophulus,  805 
to  prurigo,  807 

rubra,  803 

serum  causing,  805 

simple,  803,  804 

strawberries  causing,  804 

treatment  of,  805,  807,  808 

varieties  of,  803 

wheals  in,  803 
Uterus,  lactogen  of,  151 

VACCINATION,  630 

against  small-pox,  accidental  inoculation 

from,  636 

appearance  after,  633 
complications  of,  634 
dangers  to  unvaccinated  persons 

from,  636,  637 
epidemics  before,  631 
exanthem  from,  634 
German  law  for,  631 
in  chronic  dyspepsia,  311 
in  disturbed  nutrition,  299 
injuries  from,  635 
method  of,  632 
positive  reaction  in,  635 
second,  634 
syphilis  from,  632 
vaccinia  from  636 


916 


INDEX 


Vaccination,  antityphoid,  696 

in  constitutionally  weak  children,  299 
of  tuberculin,  738 
Vaccines  in  articular  metastasis,  151 
in  furunculosis,  815 
in  pertussis,  681 
in  typhoid  fever,  696 
Vaccinia,  636 

Vaginal  hemorrhage  of  new-born,  154,  155 
Vagus  hypertonia  in  exudative  diathesis, 

219 

Valvular  lesions  of  heart,  392 
acquired,  403 
aortic,  401,  404 
clinical  picture  of,  404 
diagnosis  of,  406 
mitral,  401,  403,  404 
prognosis  of,  406 
prophylaxis  of,  406 
symptoms  of,  405 
treatment  of,  406 
tricuspid,  405 
Varicella,  623 

clinical  picture  of,  624 
complications  of,  627 
course  of,  627 
definition  of,  623 
diagnosis  of,  628 

differentiation  from  small-pox,  628 
eruption  in,  624,  625,  626 
incubative  period  of,  624 
mouth  affected  in,  625 
organism  of,  unknown,  623 
pneumonia  arresting  eruption  in,  627 
prodromes  usually  lacking,  624 
prognosis  of,  630 
prophylaxis  of,  630 
second  attacks  rare  in,  624 
treatment  of,  630 
vocal  cords,  eruption  on,  in,  626 
vulva  affected  in,  625 
Variola,  differentiation  from  varicella,  628 
eruption  in,  628 
primary  focus  in  nose,  348 
Varioloid,  628,  631 

Vegetable  diet  in  exudative  diathesis,  223 
Vegetations,  adenoid,  353 
Vegetative  man  of  Kocher,  229 
Venous  murmurs,  393 
Ventricles  of  brain,  puncture  of,  in  hydro- 

cephalus,  483 
in   meningitis,  474 
of  heart,  weight  of,  at  birth,  1 

size  of,  at  birth,  1 
Vernix  caseosa  in  external  auditory  canal, 

355 

Verole  volante,  la  petite,  624 
Veronal  in  alimentary  intoxication,  297 

soporific  action  of,  1 16 
Verruca  vulgaris,  843 
treatment  of,  843 
planse  juvenilis,  843 

Vertebral  column,  rigidity  of,  in  tubercu- 
lous meningitis,  460 
tuberculosis  of,  in  scrofula,  735 
Vesico-umbilical  ligaments,  origin  of,  134 


Vincent's  angina,  251 

differentiated    from  diphtheritic  an- 
gina, 656,  657 
Vision  at  three  months,  32 
Vitamins  19 

in  rickets,  19,  196,  207 
in  scurvy,  19 
Vocal  cords,  eruption  of  varicella  on,  626 

spasm  of,  in  spasmophilia,  533 
Vomiting,  acetonemic,  222 
in  acute  dyspepsia,  289,  307 
in  alimentary  intoxication,  292 
in  arthritism,  222 
in  congenital  spastic  pyloric  stenosis, 

322 
in  meningococcus  meningitis,  466,  468, 

473 

in  serous  meningitis,  475 
in  tuberculous  meningitis,  459 
nervous,  327 
of  infants,  habitual,  325 
uncontrollable,  325 
periodic,  326 

Vulva,  gaping  of,  at  birth,  13 
Vulvo-vaginitis,  449 
course  of,  451 
prophylaxis  of,  451 
symptoms  of,  450 
treatment  of,  451 

WALKING  delayed  in  rickets,  197 
not  to  be  hastened,  68 
time  of  first,  33 
Warming  tub  in  subnormal  temperature, 

108 
Wart,  common,  843 

treatment  of,  843 
Washing  of  eyes,  66 
of  mouth,  unnecessary  during  first  year, 

66 
Wassermann  reaction,  751,  754,  779,  780, 

785 

Water  cancer,  246 
cereal,  65 

contents  of  adult,  1 
of  child,  1 
of  fetus,  1 
of  new-born,  1 

cure  treatment  in  chronic  dyspepsia,  314 
excretion  in  infancy,  19 
function  of,  in  metabolism,  18 
loss  of,  how  prevented,  110,  111 
method  of   calculating  amount  of,   in 

feeding,  64 
on  the  brain,  458 
retention,  19,  23 
"Watery  blood,"  116 
Weaning,  51,  306 

breast  feeding  replaced  in,  51 
feeding  before  and  after,  51 
followed  by  ovulation,  43 
gradual,  in  pregnant  women,  43 
method  of,  51 
mixed  diet  in,  51,  52 
soup  in,  51,  52 
time  for,  51 


INDEX 


917 


Weaning,  to  be  tried  before,  49,  50 
t  Weighing  of  child  to  determine  number  of 

feedings,  47 
Weight  at  birth,  23 

of  American  children,  24 
average  during  first  year,  25 
curve,  262 

in  alimentary  intoxication,  296,  298 
in  gruel  treatment  of  acute  dyspepsia, 

290 

factors  affecting,  24 
increase  by  weeks,  25 
by  years,  26 
test  of  feeding,  48 
loss  of,  in  the  new-born,  24 
of  brain,  average,  28 
periods  of  increase  in,  27 
physiologic  loss  of,  24 
relation  to  height,  26 
seasonal  increase  in,  27,  28 
table  showing  increase  in,  26 

average  increase  in,  25 
weekly  increase  of,  48 
Welfare  movement,  child,  102 
Werlhof 's  disease,  184 
idiopathic,  184 
thrombopenia  in,  184,  185 
treatment  of,  185 
Wet  feet,  care  of,  67 

Wet-nurse,  amount  of  milk  secreted  by,  48 
changing  of,  53,  73,  305 
contraction    of    syphilis    from    feeding 

syphilitic  child,  124 
diseases  detrimental  to  employing,  54 
duration  of  lactation  in,  41 
employment  agencies  supplying,  dangers 

from,  53 
expense  of,  54 
fat  contents  of  milk  of,  48 
for  premature  children,  124 
hygiene  of,  41 
mixed  feeding  by,  54 
must  not  nurse  syphilitic  child,  124 
nursing  own  child  as  well,  53 
palming  off  other  infants  as  her's,  53 
physical  examination  of,  53 
syphilitic,  danger  of  infection  from,  101 
to  be  protected  from  syphilitic  child, 

124 

to  be  secured  from  lying-in  hospital,  53 
von  Pirquet  's  reaction  of,  not  a  contra- 
indication for  nursing  child,  53 
Wassermann  reaction  to  be  made  before 

employing,  53 
Wet-nursing,  52,  124 

from  ethical  sense,  52 
Wheal,  urticarial,  803 
Wheat  flour  in  infant  feeding,  61 
Whey,  257 

carbohydrates  and,  295 
diluted,  in  intestinal  infections,  319 
formation  of,  9 

in  alimentary  intoxication,  298 
Whitehead  mouth  gag,  74 
Whole  blood  in  melena,  149 

in  umbilical  hemorrhage,  144 


Whooping  cough  (see  Pertussis),  672 
Widal  agglutination  test  in  typhoid  fever, 

695,  729 

Wilson's  disease,  524 
Winckel's  disease,  endogenous  hemolytic 

166 

form  of  sepsis  of  new-born,  146 
Windpocken,  623 

Wine,  effects  of,  on  nursing  mother,  42 
Wine  of  antimony  in  acute  dyspepsia,  308 

of  pepsin,  117 

Winking  in  tuberculous  meningitis,  462 
"Witch's"  milk,  14,  151, 
lactogen,  causing,  151 
resemblance  to  colostrum,  151 
Worms,  round,  337 
tape,  338 
thread,  338 
Wound  erysipelas  from,  713 

umbilical,  134 

Wounds,  scarlet  fever  of,  581 
Wrist,  ossification  of  bones  of,  29 
Wry  neck,  causes  of,  130 
therapy  of,  131 

X-RAYS,  diagnostic  value  of,  85 

in  diagnosis  of  bronchial  lymph  nodes. 
737 

of  cella  turcica,  236 

of  exudative  diathesis,  218 

of  infantile  scurvy,  188 

of    lymphatic   leucemia    by   para- 
vertebral  shadow,  178 

of  milary  tuberculosis  of  lung,  737 

of  myxedema,  233 

of  osteochondritis,  768 

of  osteopsathyrosis,  238 

of  rickets,  198,  204 

of  syphilis,  768 

of  thymic  enlargements,  218 

of  tuberculosis,  736,  737 

of  tuberculous  nodes,  726,  727,  729 
in  treatment  of  anemia,  174 

of  leucemia,  183,  184 

of  lupus,  821 

of  moles,  851 

of  nevus,  851 

of  purpura  hemorrhagica,  185 

of  psoriasis,  834 

of  scrofuloderma,  822 
limitations  of,  85 
Xanthelasma,  849 
Xanthelasmoidea,  825 
Xanthoma,  849 
Xeroderma,  844 
Xeroderma  pigmentosum,  847 

Y-BACILLI  in  pseudodysentery,  316 
Yawning  in  tuberculous  meningitis,  460 

ZINC  oxide  as  dusting  powder,  66 

in  chafing,  67 

in  eczema,  801 

stearate  for  umbilical  wound,  136 
Zona,  827 
Zwieback,  17 


UNIVERSITY  OF  CALIFORNIA  AT  LOS  ANGELES 

THE  UNIVERSITY  LIBRARY 
This  book  is  DUE  on  the  last  date  stamped  below 


MAR  8  4  7950 
NOV7    1950 

APR  1  3  1954 
1  0  19* 


Form  L-o 
Z0m-l,'41(1122) 


.*,-* 


LOS  AI 
LIBRA 


A    001406856    3 


